Fema Form 119 25 2 – Fill Out and Use This PDF

Enter your date of birth in 1. DATE OF BIRTH (Mo, Day, Yr.). For 2. GENDER, check FEMALE or MALE. For 3. U.S. CITIZEN, check YES, NO or PERMANENT RESIDENT. If No, enter City and Country of Birth.

For 4. RACE (Please check all that apply), check AMERICAN INDIAN or ALASKAN NATIVE, ASIAN, BLACK or AFRICAN AMERICAN, WHITE, or NATIVE HAWAIIAN or PACIFIC ISLANDER.

For 4a. ETHNICITY, check HISPANIC or LATINO or NOT HISPANIC or LATINO.

For 5. PLEASE PRINT YOUR NAME, print it as Last, First, Middle, Suffix.

Enter your STUDENT IDENTIFICATION (SID) NUMBER in 6.

For 7. HOME MAILING ADDRESS, enter the street, avenue, road no., P.O. box/city or town, and zip code.

Enter your Work Phone Number in 8, your Home Phone Number in 9 and your FAX Number in 10.

Enter your E-MAIL ADDRESS in 11.

Enter the course code and title in 12a, the course location in 12b and the date in 12c.

For 13, check NO or YES for any disabilities (including special allergies or medical disabilities) which would require special consideration during your attendance in training. If yes, indicate and describe any special considerations required on a separate sheet.

Enter the name and complete address of the organization being represented in 14a, the NFIRS # in 14b (NFA ONLY), and your current position and number of years in position in 15.

For 16, check the box(es) that best describe your organization. 16a. Jurisdiction: Foreign, DHS/FEMA, Tribal Nation, Statewide, Special District/Township, County Government, City/Town/Village, Federal/Military (non-DHS), Industry/Business. 16b. Organization: All Career, All Volunteer, Combination. 16c. Current Status: Paid Full Time, Paid Part Time, Volunteer, Disaster Reservist.

“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.”

For 19, the head of the sponsoring organization signs 19a. SIGNATURE and enters 19b. PRINTED NAME AND TITLE and 19c. DATE; 19 is not required for self study programs.

By signing this application, the head of the sponsoring organization certifies that the 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.

For an APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE, 20. ADDITIONAL ENDORSEMENTS are the 20a. SIGNATURE AND DATE (State Office) and the 20b. SIGNATURE AND DATE (FEMA Regional Office); they are NOT REQUIRED FOR SELF STUDY PROGRAMS.

21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR.