Fema Form 75 5A – Fill Out and Use This PDF

DEPARTMENT OF HOMELAND SECURITY

See Reverse for

O.M.B. NO. 1660-0100

FEDERAL EMERGENCY MANAGEMENT AGENCY

Privacy Act Statement

EXPIRES MAY 31, 2010

GENERAL ADMISSIONS APPLICATION SHORT FORM

USE THIS FORM ONLY IF APPLYING FOR NFA OFF CAMPUS COURSES (EXCLUDING REGIONAL DELIVERIES)

SECTION I - GENERAL INFORMATION

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

2. GENDER

FEMALE

MALE

3. U.S. CITIZEN

YES

NO

If No, City and Country of Birth:

4a. ETHNICITY

4b. RACE (Please check all that apply)

1.

HISPANIC or LATINO

1.

AMERICAN INDIAN or ALASKA NATIVE

2.

ASIAN

3.

BLACK or AFRICAN AMERICAN

2.

NOT HISPANIC or LATINO

4.

WHITE

5.

NATIVE HAWAIIAN or PACIFIC ISLANDER

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

6. SOCIAL SECURITY NUMBER

7. HOME ADDRESS (Street, avenue, road no./city or town, state 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

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

NO

YES

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

SECTION II - EMPLOYMENT INFORMATION

14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED

14b. NFIRS #

15. CURRENT POSITION AND NUMBER OF

(NFA STUDENTS ONLY)

YEARS IN POSITION

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

16b. ORGANIZATION

16c. CURRENT STATUS

16a. JURISDICTION

4.

SPECIAL DISTRICT/TOWNSHIP/ 7.

FOREIGN

1.

ALL CAREER

1.

PAID FULL TIME

1.

STATEWIDE

TRIBAL NATION

2.

ALL VOLUNTEER

2.

PAID PART TIME

8.

DHS/FEMA

COUNTY GOVERNMENT

2.

5.

FEDERAL/MILITARY (non-DHS)

CITY/TOWN/VILLAGE

9.

NDER/IMA

3.

COMBINATION

3.

VOLUNTEER

3.

6.

INDUSTRY/BUSINESS

DISASTER RESERVIST

4.

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, sex, 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
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)

21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR

FEMA FORM 75-5A, JUL 07

PREVIOUS EDITION OBSOLETE

EQUAL OPPORTUNITY STATEMENT

NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, sex, 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, sex, 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 volunteer 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.

INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PL 93-579, SECTION 7(b) - E.O. 9397 authorizes the collection of the SSN. The SSN is necessary because of the large number of individuals who have identical names and birthdates and whose identities can only be distinguished by the SSN. The SSN is used for recordkeeping purposes, i.e., to ensure that your academic record is maintained accurately. Disclosure of the SSN is voluntary. However, if you do not provide your SSN, another number will be substituted, which will delay processing of your application or course certificate.

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 6 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a vaild OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1670-0100). NOTE: Do not send your completed form to the above address.