Form MA-823 Supplementary Training Course Application

OMB Approval 2133-0030
Expiration Date: 4/30/2011

SUPPLEMENTARY TRAINING
COURSE APPLICATION

MAIL TO:
Maritime Administration
MD 3, Room W21-312
1200 New Jersey Avenue, S.E.
Washington, DC 20590

U.S. Department of Transportation
Maritime Administration
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 21330030. Public reporting for this collection of information is estimated to be approximately 3 minutes per response, including the time for reviewing instructions, completing and reviewing the
collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: Information Collection Clearance Officer, Maritime Administration, MAR-390, 1200 New Jersey Avenue, SE, Washington, DC 20590.

PRIVACY ACT NOTICE
This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), for individuals completing Form MA-823, Supplementary Training Course Application. The collection of this
information is authorized by 45 USC 1295 d and g. Purpose and Use – The purpose of the MA-823 is to enroll individuals in supplementary training courses offered by the Maritime Administration.
The information will also be used as general statistical information on enrollment in supplementary training courses. Effects of Nondisclosure – The disclosure of this information is voluntary;
however, the information is required in order to enroll in supplementary training courses.

PLEASE COMPLETE THE FOLLOWING PERSONAL DATA:
1. Check One of the Following to indicate the Course You are Applying for:

5. Merchant Marine Document Number:

6. Name of Employer/School

7. License Issue Number

8. License/Rating

■ Firefighting (Barge)

Firefighting (Ship)

(Applicants for firefighting training must read NOTICE and sign CONSENT
AND RELEASE below)
Other (Specify) ______________________________________________
Preferred Starting Dates: 1st Choice ____________ 2nd Choice ______________

FOR OFFICIAL USE ONLY
1. Date Received

2. Name and Address

2. Dates Course Attended
From _______________ To _______________

3. Certificate No.

4. Date Fee Paid

5. Remarks
2a. Telephone Number: (

)

3. Date of Birth (Month/Day/Year)
4. Signature of Applicant

Date
NOTICE

PARTICIPATION IN THE MARITIME ADMINISTRATION’S STANDARD FIREFIGHTING TRAINING PROGRAM (the “Program”), AT TIMES, WILL INVOLVE
EXTREMELY VIGOROUS PHYSICAL ACTIVITY AND WILL INCLUDE, BUT IS NOT LIMITED TO, THE FOLLOWING EXERCISES:
TO CONDUCT THE SEARCH AND RESCUE OF SIMULATED PERSONNEL CASUALTIES WHICH WEIGH APPROXIMATELY 150 POUNDS. THIS
SEARCH AND RESCUE WILL OCCUR IN AN ENCLOSED SMOKE/FIRE ATMOSPHERE WHILE WEARING BREATHING APPARATUS.
TO EXTINGUISH FIRES WITH AND WITHOUT THE AID OF BREATHING APPARATUS. THIS WILL INCLUDE MOVING QUICKLY AND CLIMBING
UP AND DOWN LADDERS WHILE HOLDING FIREFIGHTING EQUIPMENT SUCH AS HEAVY HOSES.
PARTICIPATION IN THIS PROGRAM CAN BE HAZARDOUS TO THE HEALTH OF INDIVIDUALS WITH CIRCULATORY PROBLEMS, HEART AILMENTS,
ALLERGIES (WHICH MAY BE TRIGGERED BY SMOKE, HEAT OR PHYSICAL ACTIVITY), OR RESPIRATORY PROBLEMS SUCH AS EMPHYSEMA AND
ASTHMA.
Each participant is urged to consult with his or her doctor if any question exists regarding his or her physical ability to participate in the Program. Individuals
who feel that the Program may be hazardous to their health should not apply for or participate in the Program. The united States government does not
provide insurance of any type for participants in the Program. The Maritime Administration reserves the right to deny training to or to terminate training of any
individual at any time when such training appears to constitute a hazard to such person or to others; in the event of such denial or termination of
training, the Maritime Administration will return all or the appropriate pro rata portion of any paid fee.
CONSENT AND RELEASE
I hereby affirm that by applying for enrollment in the Program I certify that I am aware of the inherent dangers and general health considerations in activities
connected with it.
I further understand and agree that it is not the function of the instructors to serve as the guardians of my health and safety. I also understand and agree, on
the behalf of me and my family, heirs, or assigns, that the United States of America, and its employees, agents and representatives, shall not be held liable in
any way for any occurrence in connection with my participation in the Program which may result in injury, death, or other damages to me.
In consideration of being allowed to enroll in the Program, I hereby personally assume all risks in connection with it, and I further release the United States of
America and its employees, agents and representatives, including but not limited to the persons mentioned, for any harm, injury, or damage which may befall
me while I am enrolled in the Program, including all risks connected therewith, whether foreseen or unforeseen; and further to save and hold harmless the
United States of America, and its employees, agents and representatives, from any claim by me, or my family, estate, heirs, or assigns, arising out of my
enrollment and participation in the Program.
I further state that I am of lawful age and legally competent to sign this Consent and Release; that I understand the terms herein are contractual and not
merely recital; that I have fully informed myself of the contents of this Consent and Release by reading it before I signed it; and that I have signed this
document as my own free act.
In witness thereof, I have executed this Consent and Release at ______________________________________ on _____________________, 20_____
____________________________________________________
Signature
FORM MA-823 (Rev. 3-2011)