Fillable Fema Form 75-5 - General Admissions Application

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.

SIGNATURE OF APPLICANT

DATE

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, sex, race, color, religious belief, national origin, economic status, or disability in providing

educational opportunities for its employees."

22a. SIGNATURE

22b. PRINTED NAME AND TITLE

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

23a. SIGNATURE AND DATE (State Office)

23b. SIGNATURE AND DATE (FEMA Regional Office)

24a. FOR NFA REGIONAL DELIVERY COURSES AND COURSES

24b. FOR EMI COURSES DELIVERED AT NETC, MWEOC, OR NTF

DELIVERED AT EMMITSBURG, MD. SUBMIT APPLICATION TO:

SUBMIT APPLICATION THROUGH THE APPROPRIATE STATE

EMERGENCY MANAGEMENT COORDINATOR OR FEMA REGIONAL

TRAINING MANAGER TO NETC.

NATIONAL EMERGENCY TRAINING CENTER

OFFICE OF ADMISSIONS, BLDG. I-216

16825 SOUTH SETON AVENUE

24c. FOR FIELD PROGRAM COURSES, SUBMIT APPLICATION TO

EMMITSBURG, MD. 21727

APPROPRIATE SPONSOR.

25. DISPOSITION

SIGNATURE OF REVIEWER

DATE

ACCEPTED

REJECTED

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 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 Collections 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 this address.

Fema Form 75-5 - General Admissions Application - 2007 Page 2

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