General Admissions Application Page 2
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1
2SECTION III· ENOORSEMENT AND CERTIFICATION
21a.
1 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.
Furlher, 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,
r.:llides, and
rnulations
of
NETC,
MWEOC, and
NTF.
Failure to
do so will resull in denial of
the student
stipend,
expulsion
from
the
course, and possible
barring
from uture
National
ire Academy (NFA) and
Emergency
Management
Inslilute (EMI) and FEMA·wide
courses.
SIGNATURE
OF
APPLICANT
I
DATE
22.
APPROVAL
BY
THE HEAD OF THE SPONSORING
ORGAN IZATION
"By
signing
this applicatioo,
J
certify
thai
my
organization does
nol discriminate
on
the basis
01
age, sex,
race,
color,
religious
betief,
national
origin,
economic status, or disability
in
providing
educational
opportunities
foc
its
employees.'
21,.
SIGNATURE
I
12b.
PRINT{D NAME
AND TITLE
13.
ADDITIONAL ENDORSEMEN
TS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE:
23,.
SIGNATURE AND
DATE
(State
Office)
l
13b.
SIGNATURE
AND
DATE (FEMA
Region,l
Office)
24a.
FOR
NFA
REGIONAL
DELIVERY
COURSES
AND
COURSES
24b.
FOR EMI
AND
FEMA·WIDE
COURSES
DELIVERED
AT
NETC, MWEOC,
DELIVERED AT
EMMITSBURG,
MD.
SUBMIT
APPLICATION
TO:
OR
NTF
SUBMIT APPLICATION
THROUGH THE
APPROPRIATE
STATE
EMERGENCY MANAGEMENT
COORDINATOR
OR
FEMA
REGIONAL
TRAINING MANAGER
TO
NETC.
NATIONAL
EMERGENCY TRAINING CENTER
OFFICE OF ADM ISSIONS, BLDG. 1·216
16815
SOU TH
SETON
AVENUE
24c.
FOR FIELD
PROGRAM COURSES,
SUBMIT
APPLICATION TO
EMMITSBURG,
MD.
21727
APPROPRIATE
SPONSOR.
15.
DISPOSITION
I
SIGNATURE OF
REVIEWER
I
DATE
r
ACCEPTED
r
REJECTED
EQUAL
OPPORTUNITY STATEMENT
NFA
and
EMl
are
E~ual
0r,portunil Y
institutions.
They
do
not discriminate on the
basis of ;me,
sex, race,
color, religious belief,
national
origin,
or
disability
in their
admissions
and
stu
ent·re ated
proCedures.
B oth
sctiools
make
every effort
to
ensure equi able representation
of
minorities and
women
in
their
student
Oodies.
Qualified
minority
and women candidates are
encouraged to
apply
for
all
courses.
PRIVACY ACT STATEMENT
I
~ffio~h~ ~his
informalion
is
~rovided
pursuanllo Public Law
93·579 (Privacy Act
of 1974), Title 5 United
States Code {U.S.
C.)
Section 552a,
for individuals
applying
for
i i
NFA,
EMI
or any
F MA
Agency·wide
training.
I
=i~:ederal
Fire Prevention and
Control
Act
of
1974,
as amended,
Title 15
U.S.C., Sections 2201
~.
;
Robert
T.
Stafford
Disaster Relief
and
Emer~ency
as
amende~
Title
42
U.S.C., Sections 5121
~.;
Title 44
U.S.C.,
Section
3101;
Executive
Orders 12127,
12148,
and
9397;
Title
VI of the
Civi
R~hts
and Section 50 of
the Rehabilitation
Act
of
1973.
P
UR ~OSE
S.
To determine
el
i~
i
bi
l
i
ty
for
participalion
in
NFA,
EMI
and any
FEMA
Agency-wide
training
courses.
Information
such as age,
sex,
and
ancestral heritage
are
used
or statistical
purposes
on
y.
JJ.SfS
.
Information ma~ be released to: 1)
FEMA staff
to
analyze application and enrollment
patlerns
for
specific
courses,
and
to respond to
student in~uiries; 2) a
physician
to provide me ical
assistance
to
students
who become iii
or
are injured during
courses;
3)
Members of
the Board
of Visitors
for the purpose
0
evaluatmg
pr~rammatic
statistics; 4)
sponsoring Stales,
local
officials,
or
State agencies
to update/evaluate statistics
of
NFA and EMI
and
FEMA-wide
~articipants;
5)
Members
of ongress seeking
first party information; and
6)
Agency training program contractors
and
computer
centers
performing
administrative
func
ions.
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 andior
certifying
completion of
the
course.
INEQRMAIIQN REGARDING DISQLQSURE OE YQUR SOQIAL SEQURIIY
NUMaER UNDER
~L ~J ·m
SECIION
lib),
E.O.
9397 authorizes the
ooIleclion
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
purroses,
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
wil
be
substituted,
wh
ich
will delay processing
your application or course
certificate.
PAPERWORK BURDEN
DISCLOSURE NOTICE
Public
reporting
burden for
this
form
is
estimated to average 9 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
it
displays
a
vaild
OMB control
number. Send
comments regarding
the
accuracy
of
the burden
estimate
and
any
suggestions
for reducing the
burden
to:
Information Colleclions
Management,
Department
of
Homeland
Security,
Federal
Emergency
Management Agency,
500
C Street, SW, Washington,
DC,
20472,
Paperwork
Reduction Project
(1660·0100). NOTE:
Do
not
send your
completed
form to 1his address.
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