FD-731 FBI Hazardous Devices School Course Application

1110-0074

FD-731 (Rev. 11-30-2018)
U.S. Department of Justice
Federal Bureau of Investigation

FEDERAL BUREAU OF INVESTIGATION
HAZARDOUS DEVICES SCHOOL
COURSE APPLICATION
Privacy Act Statement - Solicitation of information on this form is authorized by Title 42, United States Code (USC), Section 3771(a), which authorizes the
Director of the FBI to establish and conduct training programs for state and local criminal justice personnel, and, in the case of your Social Security Number (SSAN),
by Executive Order 9397. The primary purpose of soliciting the requested information is to determine your eligibility for enrollment in the FBI Hazardous Devices
School. Although provision of the information on this form is voluntary, failure to provide the requested information (with the exception of your SSAN) shall result
in the denial of this application. Information provided on this form may be disseminated according to the provisions of Title 5, USC, Section 552a, more commonly
known as the Privacy Act of 1974.

Does the applicant hold a security clearance? □ Yes
□ Secret □ Top Secret □ SCI

□ No

1. Date of Application

2. Type of class desired: G Certification Course
G Recertification Course
G Other ___________________
Certification applicants only: Do you understand that all travel, lodging and subsistence expenditures incurred during the
Hazardous Devices School Certification Course are to be borne by your agency?
G Yes
G No
3. Last Name

First Name

Middle Name

4. Residence Address (Street, City, State, Zip Code)

5. Birth Date

6. Place of Birth

7. Social Security Number

8. a. Name of relative to be contacted in case of emergency
9.

G

G

Male

Female

10. Height

8. b. Relationship to applicant
11. Weight

12. Do you have any physical defects which would preclude unrestricted, regular participation in the handling of live explosives
or wearing of bomb suits, chemical protective suits, respirators and other protective equipment during the Hazardous Devices
School training?

G

Yes

G

No (If “yes”, explain)

13. Name, address, and phone number of present family physician

14. E-mail Address:

a. Business _____________________________________________________
b. Personal _____________________________________________________

15. Business Telephone Number

16. Facsimile Number

17. Home Telephone Number

18. Cellular Telephone Number

19. a. Name of public safety agency where candidate employed:
c. Full Time

b. Length of employment:
20. Employment Address (Street, City, State, Zip Code)

G

Yes

G

No

21. Rank or Title

22. Certification applicants only: Is applicant replacing a current or former certified bomb technician on the squad?
If so: Name: ______________________________________ Date of his/her departure: ___________________
23. What is the squad TSL (target staffing level)? -----___ 24.
_______
Number of certified techs are currently assigned? ____

25.

The applicant will replace a current bomb tech scheduled to
retire or depart the squad? Yes______ No______
Name of departing tech if applicable: __________________

Signature of Nominating Official from the Applicant’s Agency

Name and Title (Print or Type)
Bomb Squad Information
26. a. Name of Accredited Bomb Squad to which assigned

b. Bomb Squad Identifier Number

c. Name of Bomb Squad Commander (Defined as the certified bomb technician point of contact who will speak for the squad)

d. Mailing Address of Bomb Squad (Street, City, State, Zip Code)

e. Telephone number of Bomb Squad

f. Fax number of Bomb Squad

g. E-mail of Bomb Squad
h. Signature of Bomb Squad Commander (required if the Bomb Squad Commander is employed by a different agency)

27 a. Acknowledgement (by all applicants): I am about to take a course of instruction at the Hazardous Devices School and am
aware that this course may necessitate my personal handling of live explosives, incendiary materials, hazardous chemicals, as well
as the wearing of bomb suits, respiratory protective equipment, and other personal protective equipment. I acknowledge that I am
taking this course on my own initiative. I am fully aware of the dangers and risks involved in this course of instruction.
27 b. Waiver (by non-federal employees ONLY): I realize that neither the United States Government nor the Federal Bureau of
Investigation is agreeing to act as insurers of my safety. In consideration of the permission extended to me by the United States,
through its officers and Agents, to take this course of instruction, I do hereby, to the extent permissible by law, forever discharge
the Government of the United States and all its officers, Agents, and employees, acting official or otherwise, from any and all
claims or causes of action on account of any injury to me or my property that results through no fault or wrongdoing on behalf of
the Government or its employees during the course of instruction or the handling of any hazardous device. Should a claim arise
under the terms and conditions of the Federal Tort Claims Act (FTCA, Title 28, United States Code, Sections 1346 and 2671 et
seq.), for the negligent and wrongful act or omission by an employee, in the performance of assigned duties, that result in injury
to myself or to my property, the claim shall be presented to the FBI in accordance with the FTCA for the investigation and
disposition of said claim.
28.
Signature of Applicant

Date