Form FEMA Form 119-17-2 FEMA Form 119-17-2 Request For Use of NETC Facilities

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0029
Expires December 31, 2010

REQUEST FOR USE OF NETC FACILITIES

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 6 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 this form. This collection of
information is required to obtain or retain benefits. You are not required to respond to this collection of information unless it displays a valid OMB control
number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork
Reduction Project (1660-0029). NOTE: Do not send your completed survey to the above address.
1. CONTACT PERSON

2. TELEPHONE NUMBER (Include area code)

3. ORGANIZATION

4. ADDRESS

5. NAME OF CONFERENCE/SEMINAR/MEETING

6. DATES
TO

FROM

7. ACTUAL NUMBER OF ATTENDANTS
a.

Government employees

b.

Non-government
employees (Including guest
speaker)

c.

TOTAL

8. ACTUAL NUMBER REQUIRING
OVERNIGHT LODGING
a.

Male

b.

Female

9. WILL MEALS BE REQUIRED
Yes

NOTE: Lodging checks will be made payable NOTE:
to the National Emergency Training Center

No

Food checks will be made payable to
the Food Service Contractor

10. ROOM SPACE REQUIRED
a. Meeting room

b. Breakout Rooms
(number in each room)

c. Auditorium

d. Social/Evening

11. EQUIPMENT NEEDED

12. OTHER REQUIREMENTS

DATE

13. SIGNATURE
Please return the completed form to:
Special Groups Coordinator
NATIONAL EMERGENCY TRAINING CENTER
16825 South Seton Avenue
Emmitsburg, MD. 21727
FEMA Form 119-17-2, JAN 08

PREVIOUS EDITION OBSLOETE

Phone:
Commercial:
FTS:

(301) 447-1179
652-1179