General Admissions Application
ADVERTISEMENT
1
2DEPARTMENT
OF
FEDERAL EMERGENCY
MANAGEMENT
AGENCY
GENERAL ADMISSIONS APPLICATION
See
Reverse for
Privacy Acl
Sialemeni
O.M.B.
No.
1660·0100
Expires August
31,
2013
SECTION I
· GENERAL
INFORMATION
U.S.
Citizen
rYES
I
NO
If
No.
City and Country of
Birth:
2.
NAME (Last.
Frsl.
Middle
Initial,
SuffIX)
4.
HOME
ADDRESS
(Street,
avenue,
road
no./city
or lown,
slate, and
zip code)
WORK PHONE NO. (
10.
COMPLETE
THE ITEMS BELOW
REGARDING
THE PREREQUISITES
OF
THE
INSTITUTION
DEGREE/CERTIFICATE
COURSEIFIELD OF STUDY
separate sheet)
12,. NAME
AND COMPLETE
ADDRESS
OF ORGANIZATION
BEING REPRESENTED
12b. NFIRS #
13. CURRENT POSITION AND NUMBER
OF
YEARS
(NFA
STUDENTS
IN POSITION
ONLY)
I
STATEWIDE
4.
I
SPECIAL DISTRICTITOWNSHIP
7.
I
FOREIGN
I
PAID FULL TIME
I
COUNTY GOVERNMENT
5.
I
FEDERAUMILITARY (non·DHS)
8.
I
DHSIFEMA
I
PAID
PART
TIME
ALL VOLUNTEER
I
CITYITOWNNILLAGE
6.
I
INDUSTRYIBUSINESS
9.
I
TRIBAL NATION
I
VOLUNTEER
COMBINATION
I
DISASTER RESERVIST
your activities/responsibilities as
they relale 10 the
course
for
which you are
applying
and
identify how
you
will
use
the
information obtained
from
the
course.
Attach an
I
orgarliza6ion,'
chart for the organization being represented
and
indicate your
position.
If you need
more
space, please attach
a sheet
to this application
.
•
:
..
';
..
o::c.,," ..
ONE
BOX IN EACH COLUMN THAT BEST DESCRIBES
YOUR
PRESENT PRIMARY RESPONSIBILITY
AND
TYPE OF EXPERIENCE
AS
IT RELATES TO THE
COURSE
FOR
ARE APPLYING. ALSO
ENTER THE NUMBER
OF YEARS OF
EXPERIENCE.
I
TRAININGIEDUCATION
I
SCIENTIFICIENGINEERING
4.
I
INVESTIGATION
5.
I
FIRE PREVENTION
6.
I
FIRE
SUPPRESSION
7.
I
PROGRAM/ACTIVITY
8.
I
HEALTH
9.
I
PUBLIC WORKS
lor
DISASTER
RESPONSEIRECOVERY
11.1 EMERGENCY MEDICAL
SERVICE
12.1
HAZARD
MITIGATION
13.1
EMERGENCY
PREPAREDNESS
14.1
OTHER(Speci~)
18.
DATE
OF BIRTH
17b.
TYPE OF EXPERIENCE
1.
I
INCIDENT
COMMAND
2.
I
ADMINISTRATIONiSTAFF
SUPPORT
3.
I
SUPERVISION
4.
I
BUDGET!I'LANNING
5.
I
PROGRAM
DEVElOPMENT/DELIVERY
6.
I
COORDINATIONILIAISON
7.
I
PUBLIC
EDUCATION
8.
I
CODE
DEVELOPMENT
9.
I
CODE
ENFORCEMENT/INSPECTION
lOr
SUPPORT
SERVICES
11
.1
RESEARCH
AND DEVELOPMENT
12.1
ARSON
13.1
LAW
ENFORCEMENT
14.1
DESIGN
AND PLANNING
15.1
OTHER
(Speci~)
17e.
NUMBER OF YEARS
OF EXPERIENCE
17d.
SIZE
OF
DEPARTMENT
_ _ _
_
17e.
BUSINESS TYPE
1.
I
GOVERNMENT
2.
I
EDUCATION
3.
I
FIRE SERVICE
4.
I
LAW ENFORCEMENT
5.
I
VOLUNTEER AGENCY
6.
I
EMERGENCY MANAGEMENT
7.
I
HEALTH
CARE
8.
I
PUBLIC
WORKS
I
HISPANIC
0<
LATINO
I
NOT HISPANIC or LATINO
NATIVE
2.
I
ASIAN
3.
I
BLACK
or
AFRICAN AMERICAN
4.
I
WHITE
5.
I
NATIVE HAWAIIAN
or
PACIFIC ISLANDER
FEMA Form 119-25-1, AUG 2010
PREVIOUSLY FEMA Fo rm
75·5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal