Form FEMA Form 119-25-0 FEMA Form 119-25-0 Training Registration Form

DEPARTMENT OF HOMELAND SECURITY

FOR AGENCY USE ONLY.
BARCODES, ETC.

Federal Emergency Management Agency
TRAINING REGISTRATION FORM

O.M.B. Control No. 1660-0100
Expiration: 04/30/20

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 9 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, 500 C Street, SW,
Washington, DC 20472-3100, Paperwork Reduction Project (1660-0100) NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
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 FEMA training. 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.; 6 U.S.C. Section 763a; Title 44 U.S.C., Section
3101; Executive Orders 12127 and 12148; Title VII of the Civil Rights Act of 1964; and Section 504 of the Rehabilitation Act of 1973; Section 1204 (c) of the
Implementing Recommendations of the 9/11 Commission Act of 2007. Public Law 110-53, 121 Stat. 266 (codified at 6 U.S.C. §1102). PURPOSE - To determine
eligibility for participation in FEMA training. Demographic data is used for statistical purposes only. USES - FEMA may release information to: FEMA training
agency staff and partners to analyze application and enrollment patterns; a physician providing medical assistance to students during training; Board of Visitors
members to evaluate programmatic statistics; State, local, tribal agencies to provide FEMA training statistics; Members of Congress; and FEMA training program
contractors. EFFECTS OF NONDISCLOSURE - Though voluntary, failure to provide personal information on this form may delay application processing and
course completion certification.

IMPORTANT: The form should be completed in CAPITAL LETTERS using a BLACK or DARK BLUE pen. If you use a pencil, please apply
enough pressure to ensure dark markings. Characters and marks used should be similar to the following:
Examples: A B C D E F G H

I

J K L M N O P Q R S T U V W X Y Z 1 2 3 4 5 6 7 8 9 0

Yes

SECTION 1 - GENERAL INFORMATION
1. Are you a U.S. Citizen?

Yes

No

Permanent Resident

If No, City of Birth:

Country of Birth:

2. Name as shown on valid ID (Last, First, MI, Suffix):
First Name:

Middle Initial:

Last Name:

Suffix:
Your 10-digit Student ID

3. FEMA SID

4. Date of Birth:
(mm/dd/yyyy)

5. Work Phone:
6a. Training Component (CDP, EMI, NFA, NTED) or Provider ID:
6b. Course Catalog Number, Code, Title or Program:

6c. Training Delivery Type:
6d. Training Dates:
(mm/dd/yyyy)

Resident

Non-Resident (Mobile)

Indirect

Start Date:

Distance Learning

Conference or Symposium

End Date:

6e. Training Location (City, ST or NA for Distance Learning):

7. E-mail Address:
Example: JOHN_DOE@AOL.COM

FEMA FORM 119-25-0-6 (09/14)

Use CAPITAL LETTERS and one character per block

Previous Edition Obsolete

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FOR AGENCY USE ONLY.
BARCODES, ETC.

TRAINING REGISTRATION FORM
SECTION 2 - EMPLOYMENT/POSITION INFORMATION

8a. Organization Name:
8b. Organization Street
Address:
8c. Org City:

8d. Org State:

8e. Org Zip

9a. Years in Current Position:

9b. Current Position:
10. Jurisdiction
Federal DHS

Federal (Non-DHS)

Local Government

Private Sector

Statewide/Territorial

Federal FEMA

International

Military

Special District

Tribal Nation

11. Discipline
Agriculture

Fire Service

Law Enforcement

Security and Safety

Citizen/Community Volunteer

Government Administrative

Public Health

Transportation

Education

Hazardous Materials

Public Safety Communication

Other (specify below)

Emergency Management

Healthcare

Public Works

Emergency Medical Services

Information Technology

Search and Rescue

Other Discipline
SECTION 3 - CERTIFICATION
12. Applicant Certification
I Certify that the information recorded on this application is correct. I hereby authorize the release of any and all information concerning my
enrollment in this course to the chief officer, or designee, of my organization. Further I understand that this information is available to all FEMA
Training Facilities and their Training Partners. I agree to abide by the rules, policies, and regulations of the FEMA training agencies and their
training partners. Failure to do so will result in denial of the student stipend (if applicable), expulsion from the course, and possible barring from
future courses.

Signature of Applicant

Date

SECTION 4 - AGENCY SPECIFIC

EQUAL OPPORTUNITY STATEMENT
FEMA is an equal opportunity agency. We do not discriminate on the basis of race, color religious belief, national origin, gender, age,
or disability in admissions or student-related procedures.
FEMA FORM 119-25-0-6 (09/14)

Previous Edition Obsolete

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