Fillable Fema Form 119-25-2 - General Admissions Application Short Form printable pdf download

DEPARTMENT OF HOMELAND SECURITY

O.M.B. No. 1660-0100

See Reverse for

FEDERAL EMERGENCY MANAGEMENT AGENCY

Privacy Act Statement

Expires November 30, 2016

GENERAL ADMISSIONS APPLICATION SHORT FORM

SECTION I - GENERAL INFORMATION

1. DATE OF BIRTH (Mo, Day, Yr.)

If No, City and Country of Birth:

2. GENDER

3. U.S. CITIZEN

PERMANENT

FEMALE

MALE

YES

RESIDENT

4. RACE (Please check all that apply)

4a. ETHNICITY

AMERICAN INDIAN or ALASKAN NATIVE

ASIAN

BLACK or AFRICAN AMERICAN

HISPANIC or LATINO

NATIVE HAWAIIAN or PACIFIC ISLANDER

NOT HISPANIC or LATINO

WHITE

5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)

6. STUDENT IDENTIFICATION (SID) NUMBER

7. HOME MAILING ADDRESS (Street, avenue, road no., P.O. box/city or town, and zip code)

8. WORK PHONE NO.

(

)

9. HOME PHONE NO.

(

)

10. FAX NO.

(

)

11. E-MAIL ADDRESS

12a. ENTER COURSE CODE AND TITLE

12b. COURSE LOCATION

12c. DATE

L278 NFIP/Community Rating System

13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING?

(If yes, indicate & describe any special considerations required on a separate sheet)

YES

SECTION II - EMPLOYMENT INFORMATION

14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED

14b. NFIRS #

15. CURRENT POSITION AND NUMBER OF YEARS IN

(NFA ONLY)

POSITION

N/A

16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION

16b. ORGANIZATION

16c. CURRENT STATUS

16a. JURISDICTION

PAID FULL TIME

STATEWIDE

FOREIGN

ALL CAREER

SPECIAL DISTRICT/TOWNSHIP

PAID PART TIME

COUNTY GOVERNMENT

FEDERAL/MILITARY (non-DHS)

DHS/FEMA

ALL VOLUNTEER

VOLUNTEER

COMBINATION

CITY/TOWN/VILLAGE

INDUSTRY/BUSINESS

TRIBAL NATION

DISASTER RESERVIST

SECTION III - ENDORSEMENT AND CERTIFICATION

17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001).

17b. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge, or designee, of my organization. All requests for information

shall be in writing from said chief officer or designee.

17c. Further, I understand that the National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC), and the Noble Training Facility (NTF) are not

authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis.

17d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTF. Failure to do so will result in denial of the student stipend, expulsion from the course, and possible barring

from future National Fire Academy (NFA) and Emergency Management Institute (EMI) courses.

18a. SIGNATURE OF APPLICANT

18b. DATE

19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS)

By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or disability in providing

educational opportunities for its employees.

19a. SIGNATURE

19b. PRINTED NAME AND TITLE

19c. DATE

Not required

N/A

20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS)

20a. SIGNATURE AND DATE (State Office)

20b. SIGNATURE AND DATE (FEMA Regional Office)

Not required

21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR

N/A