FEMA Form 119-25-2 "General Admissions Application Short Form"

What Is FEMA Form 119-25-2?

This is a legal form that was released by the U.S. Department of Homeland Security - Federal Emergency Management Agency on February 1, 2012 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest available edition released by the U.S. Department of Homeland Security - Federal Emergency Management Agency;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of FEMA Form 119-25-2 by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Federal Emergency Management Agency.

ADVERTISEMENT
ADVERTISEMENT

Download FEMA Form 119-25-2 "General Admissions Application Short Form"

825 times
Rate (4.7 / 5) 40 votes
DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0100
See Reverse for
FEDERAL EMERGENCY MANAGEMENT AGENCY
Privacy Act Statement
Expires November 30, 2016
GENERAL ADMISSIONS APPLICATION SHORT FORM
SECTION I - GENERAL INFORMATION
1. DATE OF BIRTH (Mo, Day, Yr.)
If No, City and Country of Birth:
2. GENDER
3. U.S. CITIZEN
PERMANENT
FEMALE
MALE
YES
NO
RESIDENT
4. RACE (Please check all that apply)
4a. ETHNICITY
1.
2.
3.
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
HISPANIC or LATINO
4.
5.
NATIVE HAWAIIAN or PACIFIC ISLANDER
NOT HISPANIC or LATINO
WHITE
5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)
6. STUDENT IDENTIFICATION (SID) NUMBER
7. HOME MAILING ADDRESS (Street, avenue, road no., P.O. box/city or town, and zip code)
8. WORK PHONE NO.
(
)
9. HOME PHONE NO.
(
)
10. FAX NO.
(
)
11. E-MAIL ADDRESS
12a. ENTER COURSE CODE AND TITLE
12b. COURSE LOCATION
12c. DATE
L278 NFIP/Community Rating System
13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING?
(If yes, indicate & describe any special considerations required on a separate sheet)
NO
YES
SECTION II - EMPLOYMENT INFORMATION
14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
14b. NFIRS #
15. CURRENT POSITION AND NUMBER OF YEARS IN
(NFA ONLY)
POSITION
N/A
16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
16b. ORGANIZATION
16c. CURRENT STATUS
16a. JURISDICTION
1.
PAID FULL TIME
.
1.
STATEWIDE
4.
7.
FOREIGN
1.
ALL CAREER
SPECIAL DISTRICT/TOWNSHIP
2.
PAID PART TIME
2.
COUNTY GOVERNMENT
5.
FEDERAL/MILITARY (non-DHS)
8.
DHS/FEMA
2.
ALL VOLUNTEER
VOLUNTEER
3.
COMBINATION
3.
CITY/TOWN/VILLAGE
6.
INDUSTRY/BUSINESS
9.
TRIBAL NATION
3.
DISASTER RESERVIST
4.
SECTION III - ENDORSEMENT AND CERTIFICATION
17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001).
17b. 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.
17c. 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.
17d. 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.
18a. SIGNATURE OF APPLICANT
18b. DATE
19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS)
By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or disability in providing
educational opportunities for its employees.
19a. SIGNATURE
19b. PRINTED NAME AND TITLE
19c. DATE
Not required
N/A
N/A
20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS)
20a. SIGNATURE AND DATE (State Office)
20b. SIGNATURE AND DATE (FEMA Regional Office)
Not required
Not required
21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR
N/A
FEMA Form 119-25-2, (2/12)
PREVIOUS EDITION FF75-5A OBSOLETE
DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0100
See Reverse for
FEDERAL EMERGENCY MANAGEMENT AGENCY
Privacy Act Statement
Expires November 30, 2016
GENERAL ADMISSIONS APPLICATION SHORT FORM
SECTION I - GENERAL INFORMATION
1. DATE OF BIRTH (Mo, Day, Yr.)
If No, City and Country of Birth:
2. GENDER
3. U.S. CITIZEN
PERMANENT
FEMALE
MALE
YES
NO
RESIDENT
4. RACE (Please check all that apply)
4a. ETHNICITY
1.
2.
3.
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
HISPANIC or LATINO
4.
5.
NATIVE HAWAIIAN or PACIFIC ISLANDER
NOT HISPANIC or LATINO
WHITE
5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)
6. STUDENT IDENTIFICATION (SID) NUMBER
7. HOME MAILING ADDRESS (Street, avenue, road no., P.O. box/city or town, and zip code)
8. WORK PHONE NO.
(
)
9. HOME PHONE NO.
(
)
10. FAX NO.
(
)
11. E-MAIL ADDRESS
12a. ENTER COURSE CODE AND TITLE
12b. COURSE LOCATION
12c. DATE
L278 NFIP/Community Rating System
13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING?
(If yes, indicate & describe any special considerations required on a separate sheet)
NO
YES
SECTION II - EMPLOYMENT INFORMATION
14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
14b. NFIRS #
15. CURRENT POSITION AND NUMBER OF YEARS IN
(NFA ONLY)
POSITION
N/A
16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
16b. ORGANIZATION
16c. CURRENT STATUS
16a. JURISDICTION
1.
PAID FULL TIME
.
1.
STATEWIDE
4.
7.
FOREIGN
1.
ALL CAREER
SPECIAL DISTRICT/TOWNSHIP
2.
PAID PART TIME
2.
COUNTY GOVERNMENT
5.
FEDERAL/MILITARY (non-DHS)
8.
DHS/FEMA
2.
ALL VOLUNTEER
VOLUNTEER
3.
COMBINATION
3.
CITY/TOWN/VILLAGE
6.
INDUSTRY/BUSINESS
9.
TRIBAL NATION
3.
DISASTER RESERVIST
4.
SECTION III - ENDORSEMENT AND CERTIFICATION
17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001).
17b. 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.
17c. 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.
17d. 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.
18a. SIGNATURE OF APPLICANT
18b. DATE
19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS)
By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or disability in providing
educational opportunities for its employees.
19a. SIGNATURE
19b. PRINTED NAME AND TITLE
19c. DATE
Not required
N/A
N/A
20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS)
20a. SIGNATURE AND DATE (State Office)
20b. SIGNATURE AND DATE (FEMA Regional Office)
Not required
Not required
21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR
N/A
FEMA Form 119-25-2, (2/12)
PREVIOUS EDITION FF75-5A OBSOLETE
22a. DISPOSITION
22c. DATE
20b. SIGNATURE OF REVIEWER
ACCEPTED
REJECTED
EQUAL OPPORTUNITY STATEMENT
NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, gender, 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, gender, 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 voluntary 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.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 6 minutes. The burden estimate includes the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid
OMB control number is displayed on this form. 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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork
Reduction Project (1660-0100) NOTE: Do not send your completed form to this address.
Page of 2