Fema Form 119 25 1 – Fill Out and Use This PDF

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

SECTION III - ENDORSEMENT AND CERTIFICATION

21a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (18 U.S.C. 1001).

21b. 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 or designee.

21c. 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.

21d. 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.

22. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION

"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."

23. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE:

EQUAL OPPORTUNITY STATEMENT

NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, gender, race, color, religious belief, national origin, or disability in their admissions and student- related procedures. Both schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified minority and women candidates are encouraged to apply for all courses.

PRIVACY ACT STATEMENT

GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.) Section 552a, for individuals applying for admission to NFA or EMI.

AUTHORITY - Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et. seq.; Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, Title 42 U.S.C., Sections 5121 et. seq.; Title 44 U.S.C., Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Rights Act of 1964; and Section 504 of the Rehabilitation Act of 1973.

PURPOSES - To determine eligibility for participation in NFA and EMI courses. Information such as age, gender, and ancestral heritage are used for statistical purposes only.

USES - Information may be released to: 1) FEMA staff to analyze application and enrollment patterns for specific courses, and to respond to student inquiries; 2) a physician to provide medical assistance to students who become ill or are injured during courses; 3) Members of the Board of Visitors for the purpose of evaluating programmatic statistics; 4) sponsoring States, local officials, or State agencies to update/evaluate statistics of NFA and EMI participants; 5) Members of Congress seeking first party information; and 6) Agency training program contractors and computer centers performing administrative functions.

EFFECTS OF NONDISCLOSURE - Personal information is provided on a voluntary basis. Failure to provide information on this form, however, may result in a delay in processing your application and/or certifying completion of the course.

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 9 minutes. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0100) NOTE: Do not send your completed form to this

address.