<table style="width:100%;">
<colgroup>
<col style="width: 20%" />
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<col style="width: 6%" />
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<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 2%" />
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<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><p><strong>U.S. DEPARTMENT OF HOMELAND
SECURITY</strong></p>
<h5 id="federal-emergency-management-agency">FEDERAL EMERGENCY
MANAGEMENT AGENCY</h5>
<h1 id="general-admissions-application">GENERAL ADMISSIONS
APPLICATION</h1></td>
<td colspan="5">See Reverse for Privacy Act Statement</td>
<td colspan="2"><p><em>O.M.B. No. 1660-0007</em></p>
<p><em>Expires February 28, 2007</em></p></td>
</tr>
<tr class="even">
<td colspan="3"><h2 id="section-i-general-information">SECTION I –
GENERAL INFORMATION</h2></td>
<td colspan="6">1. <mark>U.S. Citizen</mark> Yes No</td>
<td colspan="9"><blockquote>
<p>If No, City and Country of Birth:</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="12"><p>2. <mark>NAME <em>(Last, First, Middle Initial,
Suffix)</em></mark></p>
<p>     </p></td>
<td colspan="6"><p>3. <mark>SOCIAL SECURITY NO.</mark></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="7" rowspan="4"><p>4. <mark>MAILING ADDRESS <em>(Street,
avenue, road no., city or town, state, and zip code)</em></mark></p>
<p><em>     </em></p></td>
<td colspan="11">5. <mark>WORK PHONE NO.</mark> (     )      </td>
</tr>
<tr class="odd">
<td colspan="11">6. <mark>HOME PHONE NO.</mark> (     )      </td>
</tr>
<tr class="even">
<td colspan="11">7. <mark>FAX NO.</mark> (     )      </td>
</tr>
<tr class="odd">
<td colspan="11">8. <mark>E-MAIL ADDRESS:</mark>      </td>
</tr>
<tr class="even">
<td colspan="5">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)</td>
<td colspan="5">9b. COURSE LOCATION</td>
<td colspan="8">9c. DATES REQUESTED (Please give three choices)</td>
</tr>
<tr class="odd">
<td colspan="5">_<strong><u>E392 EMI HIGHER EDUCATION PROJECT
CONFERENCE</u></strong></td>
<td colspan="5">______<u><strong>NETC</strong></u> _____</td>
<td colspan="5"><strong><u>5-7 June 2007</u></strong></td>
<td colspan="2">_______</td>
<td>____________</td>
</tr>
<tr class="even">
<td colspan="18">10. COMPLETE THE ITEM BELOW REGARDING THE
PRE-REQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING</td>
</tr>
<tr class="odd">
<td colspan="2"><p>INSTITUTION</p>
<p><strong>_______________<mark><u>NOT
APPLICABLE_</u></mark>______</strong></p></td>
<td colspan="6"><p>DEGREE/CERTIFICATE</p>
<p><strong><u>_______<mark>NOT
APPLICABLE_</mark>_____</u></strong></p></td>
<td colspan="5"><p>DATE EARNED</p>
<p><strong><mark><u>NOT APPLICABLE</u></mark></strong></p></td>
<td colspan="5"><p>COURSE/FIELD OF STUDY</p>
<p><strong>___________<u><mark>NOT APPLICABLE</mark>
_</u>____</strong></p></td>
</tr>
<tr class="even">
<td colspan="18">11. DO YOU HAVE ANY DISABILITIES <em>(Including special
allergies or medical disabilities)</em> WHICH WOULD REQUIRE SPECIAL
ASSISTANCE DURING YOUR ATTENDANCE AT NETC or MWEOC? NO YES (If yes,
describe &amp; indicate any special assistance required on a separate
sheet)</td>
</tr>
<tr class="odd">
<td colspan="18"><h2
id="section-ii-employment-information-and-authorization">SECTION II –
EMPLOYMENT INFORMATION AND AUTHORIZATION</h2></td>
</tr>
<tr class="even">
<td colspan="8"><p>12a. <mark>NAME AND COMPLETE ADDRESS OF ORGANIZATION
BEING REPRESENTED</mark></p>
<p>     </p></td>
<td colspan="4"><p>12b. NFIRS#</p>
<p>(NFA STUDENTS ONLY)</p></td>
<td colspan="6"><p>13. <mark>CURRENT POSITION AND NUMBER OF YEARS IN
POSITION</mark></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="18">14. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR
ORGANIZATION</td>
</tr>
<tr class="even">
<td colspan="8">14a. JURISDICTION</td>
<td colspan="6">14b. ORGANIZATION</td>
<td colspan="4">15. CURRENT STATUS</td>
</tr>
<tr class="odd">
<td><p>1. STATEWIDE</p>
<p>2. COUNTY GOVERNMENT</p>
<p>3. CITY/TOWN/VILLAGE</p></td>
<td colspan="3"><p>4. SPECIAL DISTRICT/TOWNSHIP/<br />
TRIBAL NATION</p>
<p>5. FEDERAL/MILITARY (non-DHS)</p>
<p>6. INDUSTRY/BUSINESS</p></td>
<td colspan="4"><p>7. FOREIGN</p>
<p>8. DHS/FEMA</p>
<p>9. NDER/IMA</p></td>
<td colspan="6"><p>1. ALL CAREER</p>
<p>2. ALL VOLUNTEER</p>
<p>3. COMBINATION</p></td>
<td colspan="4"><p>1. PAID FULL TIME</p>
<p>2. PAID PART TIME</p>
<p>3. VOLUNTEER</p>
<p>4. DISASTER RESERVIST</p></td>
</tr>
<tr class="even">
<td colspan="18"><p>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, indicating your position. If you need more space, please
attach a sheet to this application.</p>
<p><strong><mark>NOT APPLICABLE</mark></strong></p></td>
</tr>
<tr class="odd">
<td colspan="18">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<strong>. <mark>* NOT APPLICABLE</mark></strong></td>
</tr>
<tr class="even">
<td colspan="6"><blockquote>
<p>17a. PRIMARY RESPONSIBILITY</p>
<p>1.  MANAGEMENT</p>
<p>2.  TRAINING/EDUCATION</p>
<p>3.  SCIENTIFIC/ENGINEERING</p>
<p>4.  INVESTIGATION</p>
<p>5.  FIRE PREVENTION</p>
<p>6.  FIRE SUPPRESSION</p>
<p>7.  PROGRAM/ACTIVITY</p>
<p>8.  HEALTH</p>
<p>9.  PUBLIC WORKS</p>
<p>10.  DISASTER RESPONSE/RECOVERY</p>
<p>11.  EMERGENCY MEDICAL SERVICES</p>
<p>12.  HAZARD MITIGATION</p>
<p>13.  EMERGENCY PREPAREDNESS</p>
<p>14.  OTHER (Specify)</p>
<p>17c. NUMBER OF YEARS OF EXPERIENCE ___________________</p>
</blockquote></td>
<td colspan="12"><p>17b. TYPE OF EXPERIENCE</p>
<blockquote>
<p>1.  INCIDENT COMMAND</p>
<p>2.  ADMINISTRATION/STAFF SUPPORT</p>
<p>3.  SUPERVISION</p>
<p>4.  BUDGET/PLANNING</p>
<p>5.  PROGRAM DEVELOPMENT/DELIVERY</p>
<p>6.  COORDINATION/LIAISON</p>
<p>7.  PUBLIC EDUCATION</p>
<p>8.  CODE DEVELOPMENT</p>
<p>9.  CODE ENFORCEMENT/INSPECTION</p>
<p>10.  SUPPORT SERVICES</p>
<p>11.  RESEARCH AND DEVELOPMENT</p>
<p>12.  ARSON</p>
<p>13.  LAW ENFORCEMENT</p>
<p>14.  DESIGN AND PLANNING</p>
<p>15.  OTHER (Specify) _______ 17d. SIZE OF DEPARTMENT ________</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="6"><p>18. <mark>DATE OF BIRTH (Mo. Day, Yr.)</mark></p>
<p>     </p></td>
<td colspan="12"><p>19. <mark>SEX</mark></p>
<blockquote>
<p> Male Female</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2"><p>20a. ETHNICITY</p>
<p>1. HISPANIC or LATINO</p>
<p>2. NOT HISPANIC or LATINO</p></td>
<td colspan="16"><p>20b. PLEASE CHECK THE RACE(S) WHICH BEST APPLIES TO
YOU (Providing this information is voluntary)</p>
<p>1. AMERICAN INDIAN or ALASKAN NATIVE 2. ASIAN 3. BLACK or AFRICAN
AMERICAN</p>
<p>4. WHITE 5. NATIVE HAWAIIAN or PACIFIC ISLANDER</p></td>
</tr>
</tbody>
</table>

FEMA Form 75-5, FEB 04 REPLACES ALL PREVIOUS EDITIONS

+----------------+----------------+----------------------+---+----------+
| ## SE          |                |                      |   |          |
| CTION III -- E |                |                      |   |          |
| NDORSEMENT 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     |                |                      |   |          |
| officer or     |                |                      |   |          |
| designee.      |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| 21c. Further,  |                |                      |   |          |
| I understand   |                |                      |   |          |
| that, National |                |                      |   |          |
| Emergency      |                |                      |   |          |
| Training       |                |                      |   |          |
| Center (NETC), |                |                      |   |          |
| the Mount      |                |                      |   |          |
| Weather        |                |                      |   |          |
| Emergency      |                |                      |   |          |
| Operations     |                |                      |   |          |
| Center         |                |                      |   |          |
| (MWEOC), and   |                |                      |   |          |
| the Noble      |                |                      |   |          |
| Training       |                |                      |   |          |
| Center (NTC)   |                |                      |   |          |
| 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 NTC.       |                |                      |   |          |
| 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   |                |                      |   | DATE     |
| APPLICANT      |                |                      |   |          |
|                |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| **22. APPROVAL |                |                      |   |          |
| BY THE HEAD OF |                |                      |   |          |
| THE SPONSORING |                |                      |   |          |
| O              |                |                      |   |          |
| RGANIZATION:** |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| ![](medi       |                |                      |   |          |
| a/image1.png){ |                |                      |   |          |
| width="2.54166 |                |                      |   |          |
| 66666666665in" |                |                      |   |          |
| heigh          |                |                      |   |          |
| t="0.804166666 |                |                      |   |          |
| 6666667in"}"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            |   |          |
|                |                |                      |   |          |
|                |                | Deputy               |   |          |
|                |                | Superintendent, EMI  |   |          |
+----------------+----------------+----------------------+---+----------+
| 23\.           |                |                      |   |          |
| Additional     |                |                      |   |          |
| endorsements   |                |                      |   |          |
| for            |                |                      |   |          |
| application to |                |                      |   |          |
| the Emergency  |                |                      |   |          |
| Management     |                |                      |   |          |
| Institute:     |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| 23a. SIGNATURE |                | 23b. SIGNATURE AND   |   |          |
| AND DATE       |                | DATE (FEMA Regional  |   |          |
| (State Office) |                | Office)              |   |          |
|                |                |                      |   |          |
| [NOT           |                | [NOT                 |   |          |
| APPL           |                | APPLICABLE]{.mark}   |   |          |
| ICABLE]{.mark} |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| 24a. FOR NFA   |                | 24b. FOR EMI COURSES |   |          |
| REGIONAL       |                | DELIVERED AT NETC,   |   |          |
| DELIVERY       |                | MWEOC, OR NTC,       |   |          |
| COURSES AND    |                | SUBMIT APPLICATION   |   |          |
| COURSES        |                | THROUGH THE          |   |          |
| DELIVERED AT   |                | APPROPRIATE STATE    |   |          |
| EMMITSBURG,    |                | EMERGENCY MANAGEMENT |   |          |
| MD. SUBMIT     |                | COORDINATOR OR FEMA  |   |          |
| APPLICATION    |                | REGIONAL TRAINING    |   |          |
| TO:            |                | MANAGER TO NETC.     |   |          |
|                |                |                      |   |          |
| ### NATION     |                | 24c. FOR FIELD       |   |          |
| AL EMERGENCY T |                | PROGRAM COURSES,     |   |          |
| RAINING CENTER |                | SUBMIT APPLICATION   |   |          |
|                |                | TO APPROPRIATE       |   |          |
| > **OFFICE OF  |                | SPONSOR.             |   |          |
| > ADMISSIONS,  |                |                      |   |          |
| > BLDG.        |                |                      |   |          |
| > I-216**      |                |                      |   |          |
| >              |                |                      |   |          |
| > **16825      |                |                      |   |          |
| > SOUTH SETON  |                |                      |   |          |
| > AVENUE**     |                |                      |   |          |
|                |                |                      |   |          |
| ### EMMITSB    |                |                      |   |          |
| URG, MD. 21727 |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| 25\.           | SIGNATURE OF   |                      | D |          |
| DISPOSITION    | REVIEWER       |                      | A |          |
|                |                |                      | T |          |
|  ACCEPTED    |                |                      | E |          |
| REJECTED       |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+
| ####           |                |                      |   |          |
|  EQUAL OPPORTU |                |                      |   |          |
| NITY 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 |                |                      |   |          |
| s              |                |                      |   |          |
| tudent-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.           |                |                      |   |          |
| ]{.underline}; |                |                      |   |          |
| Robert T.      |                |                      |   |          |
| Stafford       |                |                      |   |          |
| Disaster       |                |                      |   |          |
| Relief and     |                |                      |   |          |
| Emergency      |                |                      |   |          |
| Assistance     |                |                      |   |          |
| Act, as        |                |                      |   |          |
| amended, Title |                |                      |   |          |
| 42 U.S.C.,     |                |                      |   |          |
| Sections 5121  |                |                      |   |          |
| [et.           |                |                      |   |          |
| seq.           |                |                      |   |          |
| ]{.underline}; |                |                      |   |          |
| Title 44       |                |                      |   |          |
| U.S.C.,        |                |                      |   |          |
| Section 3101;  |                |                      |   |          |
| Executive      |                |                      |   |          |
| Orders 12127,  |                |                      |   |          |
| 12148, and     |                |                      |   |          |
| 9397; Title VI |                |                      |   |          |
| of the Civil   |                |                      |   |          |
| Rights Act of  |                |                      |   |          |
| 19764; 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 |                |                      |   |          |
| Boards of      |                |                      |   |          |
| Visitors for   |                |                      |   |          |
| the purpose of |                |                      |   |          |
| evaluating     |                |                      |   |          |
| programmatic   |                |                      |   |          |
| statistics; 4) |                |                      |   |          |
| sponsoring     |                |                      |   |          |
| states, local  |                |                      |   |          |
| officials, or  |                |                      |   |          |
| state agencies |                |                      |   |          |
| to             |                |                      |   |          |
| u              |                |                      |   |          |
| pdate/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             |                |                      |   |          |
| )]{.underline} |                |                      |   |          |
| -** 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       |                |                      |   |          |
| record-keeping |                |                      |   |          |
| 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.   |                |                      |   |          |
|                |                |                      |   |          |
| #### PAPERW    |                |                      |   |          |
| ORK BURDEN DIS |                |                      |   |          |
| CLOSURE 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 and |                |                      |   |          |
| submitting the |                |                      |   |          |
| form. You are  |                |                      |   |          |
| not required   |                |                      |   |          |
| to respond to  |                |                      |   |          |
| this           |                |                      |   |          |
| collection of  |                |                      |   |          |
| information    |                |                      |   |          |
| unless a valid |                |                      |   |          |
| OMB control    |                |                      |   |          |
| number is      |                |                      |   |          |
| displayed in   |                |                      |   |          |
| the upper      |                |                      |   |          |
| right corner   |                |                      |   |          |
| of this form.  |                |                      |   |          |
| Send comments  |                |                      |   |          |
| regarding the  |                |                      |   |          |
| accuracy of    |                |                      |   |          |
| the burden     |                |                      |   |          |
| estimate and   |                |                      |   |          |
| any            |                |                      |   |          |
| suggestions    |                |                      |   |          |
| for reducing   |                |                      |   |          |
| the burden to: |                |                      |   |          |
| Information    |                |                      |   |          |
| Collections    |                |                      |   |          |
| Management,    |                |                      |   |          |
| U.S.           |                |                      |   |          |
| Department of  |                |                      |   |          |
| Homeland       |                |                      |   |          |
| Security,      |                |                      |   |          |
| Federal        |                |                      |   |          |
| Emergency      |                |                      |   |          |
| Management     |                |                      |   |          |
| Agency, 500 C  |                |                      |   |          |
| Street, SW,    |                |                      |   |          |
| Washington, DC |                |                      |   |          |
| 20472. **NOTE: |                |                      |   |          |
| Do not send    |                |                      |   |          |
| your completed |                |                      |   |          |
| form to this   |                |                      |   |          |
| address**.     |                |                      |   |          |
| Please return  |                |                      |   |          |
| it to the      |                |                      |   |          |
| appropriate    |                |                      |   |          |
| address shown  |                |                      |   |          |
| in block 24.   |                |                      |   |          |
+----------------+----------------+----------------------+---+----------+