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General Admissions Application

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General Admissions Application
General Admissions Application
20b. RACE (Please check all that apply)
19. SEX
DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
GENERAL ADMISSIONS APPLICATION
See Reverse for
Privacy Act Statement
O.M.B. No. 1660-0100
Expires May 31, 2010
SECTION I - GENERAL INFORMATION
1. U.S. Citizen
YES
NO
If No, City and Country of Birth:
2. NAME (Last, First, Middle Initial, Suffix)
3. SOCIAL SECURITY No.
4. MAILING ADDRESS (Street, avenue, road no./city or town, state, and zip code)
5. WORK PHONE NO. ( )
6. HOME PHONE NO. ( )
7. FAX NO. ( )
8. E-MAIL ADDRESS:
9a. ENTER COURSE CODE AND TITLE: (If you wish to apply for more than one course,
please attach a sheet of paper to this application)
9b. COURSE LOCATION
9c. DATES REQUESTED (Please give three choices)
10. COMPLETE THE ITEM BELOW REGARDING THE PRE-REQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING
INSTITUTION DEGREE/CERTIFICATE DATE EARNED COURSE/FIELD OF STUDY
11. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE IN TRAINING
(If yes, describe & indicate any special assistance required on a seperate sheet)
NO YES
SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION
12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED 12b. NFIRS #
(NFA STUDENTS
ONLY)
13. CURRENT POSITION AND NUMBER OF YEARS
IN POSITION
14 a. JURISDICTION
1.
2.
3.
14. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
STATEWIDE
COUNTY GOVERNMENT
CITY/TOWN/VILLAGE
4.
5.
6.
INDUSTRY/BUSINESS
FEDERAL/MILITARY (non-DHS)
SPECIAL DISTRICT/TOWNSHIP/
TRIBAL NATION
7.
8.
9.
FOREIGN
DHS/FEMA
NDER/IMA
14 b. ORGANIZATION
1.
2.
3.
ALL CAREER
ALL VOLUNTEER
COMBINATION
15. CURRENT STATUS
1.
2.
3.
4.
PAID FULL TIME
PAID PART TIME
VOLUNTEER
DISASTER RESERVIST
16. Briefly describe your activities/responsibilities as they relate to the course for which you are applying and identify how you will use the information obtained from the course. Attach an
organizational chart for the organization being represented, indicate your position. If you need more space, please attach a sheet to this application.
FEMA Form 75-5, JUL 07
17. CHECK ONE BOX IN EACH COLUMN THAT BEST DESCRIBES YOUR PRESENT PRIMARY RESPONSIBILITY AND TYPE OF EXPERIENCE AS IT RELATES TO THE COURSE FOR
WHICH YOU ARE APPLYING. ALSO ENTER THE NUMBER OF YEARS OF EXPERIENCE.
17a. PRIMARY RESPONSIBILITY 17b. TYPE OF EXPERIENCE
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.
11. 11.
12. 12.
13. 13.
14. 14.
15.
MANAGEMENT
TRAINING/EDUCATION
SCIENTIFIC/ENGINEERING
INVESTIGATION
FIRE PREVENTION
FIRE SUPPRESSION
PROGRAM/ACTIVITY
HEALTH
PUBLIC WORKS
Male
DISASTER RESPONSE/RECOVERY
EMERGENCY MEDICAL SERVICE
HAZARD MITIGATION
EMERGENCY PREPAREDNESS
OTHER (Specify)
DESIGN AND PLANNING
LAW ENFORCEMENT
ARSON
RESEARCH AND DEVELOPMENT
SUPPORT SERVICES
CODE ENFORCEMENT/INSPECTION
CODE DEVELOPMENT
PUBLIC EDUCATION
COORDINATION/LIAISON
PROGRAM DEVELOPMENT/DELIVERY
BUDGET/PLANNING
SUPERVISION
ADMINISTRATION/STAFF SUPPORT
INCIDENT COMMAND
OTHER (Specify)
17c. NUMBER OF YEARS OF EXPERIENCE
17d. SIZE OF DEPARTMENT
18. DATE OF BIRTH
Female
20a. ETHNICITY
HISPANIC or LATINO
NOT HISPANIC or LATINO
AMERICAN INDIAN or ALASKA NATIVE
ASIAN
BLACK or AFRICAN AMERICAN WHITE
NATIVE HAWAIIAN or PACIFIC ISLANDER
PREVIOUS EDITION OBSOLETE
1. 2.
3.
4. 5.
General Admissions Application
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