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CM-2004-005GAS U.S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY GENERAL ADMISSIONS APPLICATION SECTION I - GENERAL INFORMATION 2. NAME (Last, First, Middle Initial, Suffix) Smith, David H. See Reverse for Privacy Act Statement O.M.B. No. 1660-0007 Expires February 28, 2007 1. U.S. Citizen ❑✓ YES ❑ NO If No, City and Country of Birth: 4. MAILING ADDRESS (Street, avenue, road no., city or town, state, and zip code) 551 CR 176 Georgetown, TX 78628 9a. ENTER COURSE CODE AND 111 LE:(If you wish to apply for more than one course, please attach a sheet of paper to this application) Executive Development R123 3. SOCIAL SECURITY NO. 464-13-6245 5. WORK PHONE NO. (512) 218-3200 6. HOME PHONE NO. (512) 259-9563 7. FAX NO. (512) 218-5594 8. E-MAIL ADDRESS: dhsmith@round-rock.tx.us 9b. COURSE LOCATION NFA 9c. DATES REQUESTED (Please give three choices) 4/18/05 5/2/05 5/16/05 10. COMPLETE THE ITEM BELOW REGARDING THE PRE -REQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING INSTITUTION DEGREE/CERTIFICATE DATE EARNED COURSE/FIELD OF STUDY 11. DO YOU HAVE ANY DISABILITIES ancludin special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE AT NETC or MWEOC? NO YESE (If yes, describe & indicate any special assistance required on a separate sheet) SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION 12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED Round Rock Fire Department 203 Commerce Blvd. Round Rock, TX 78664 12b. NFIRS # 13. CURRENT POSITION AND NUMBER (NFA STUDENTS OF YEARS IN POSITION ONLY) Interim FC for 4 months, BC prior for 10 years 14. CHECK THE BOX S) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION 14a. JURISDICTION 3. City/TownNillage 14b. ORGANIZATION 1. All Career 15. CURRENT STATUS 1. Paid Full -Time 16. Briefly describe your activities/responsibilities as they relate to the course for which you are.applyyiing and identify how you will use the information obtained from the course. Attach an organizational chart for the organization being represented, indicate your position. If you need more space, please attach a sheet to this application. See attachment Available for any of the above dates for this course or any of these 7/11/05, 08/08/05, 09/19/05 and will pass on stipend due to previous course this year. 17. SELECT ONE ITEM IN EACH COLUMN THAT BEST DESCRIBES YOUR PRESENT PRIMARY RESPONSIBLITY AND TYPE OF EXPERIENCE AS IT RELATES TO THE COURSE FOR WHICH YOU ARE APPLYING. ALSO ENTER THE NUMBER OF YEARS OF EXPERIENCE. 1. Management 2. Administration/Staff Support 17c. NUMBER OF YEARS OF EXPERIENCE 1 7d. SIZE OF DEPARTMENT 18. DATE OF BIRTH (Mo. Day, Yr.) 3/18/60 20a. ETHNICITY 1. ❑ HISPANIC or LATINO 2. Q NOT HISPANIC or LATINO 19. SEX ❑✓ Male ❑ Female 20b. RACE (Please check all that apply) 1. ❑ AMERICAN INDIAN or ALASKA NATIVE 2. ❑ ASIAN 3. ❑ BLACK or AFRICAN AMERICAN 4. El WIIITE 5. ❑ NATIVE HAWAIIAN or PACIFIC ISLANDER FEMA Form 75-5, FEB 04 REPLACES ALL PREVIOUS EDITIONS Reset All Fields SECTION III - ENDORSEMENT AND CERTIFICATION 21a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (18 U.S.C. 1001). 21b. 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. 21c. Further, I understand that, National Emergency Training Center (NETC), the ML Weather Emergency Operations Center (MWEOC ), and the Noble Training Center (NTC) are not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis. 21d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTC. 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. SIGNATURE OF APPLICANT 22. APPROVAL BY THE HEAD OF TUB .WT4 OCRC, "By signing this application, I certify that my organization does not discriminate oia tji�h�sis'of`,�e,'se; Fade, <.afor disability in providing educational opportunities for its employees." ,• '' .E DATE o+_s belief, national origin, economic status, or • • 23. Additional endorsements for applicatidn•to tlle'Erpbrg¢ncyManagement Institute: 23a. SI Nigi AND DATE (State Office) 23b. SIGNATURE AND DATE ( FEMA Regional Office) 24a. FOR NFA REGIONAL DELIVERY COURSES AND COURSES DELIVERED AT EMMITSBURG, MD. SUBMIT APPLICATION TO: NATIONAL EMERGENCY TRAINING CENTER OFFICE OF ADMISSIONS, BLDG. I-216 16825 SOUTH SETON AVENUE EMMITSBURG, MD. 21727 24b. FOR EMI COURSES DELIVERED AT NETC, MWEOC, OR NTC SUBMIT APPLICATION THROUGH THE APPROPRIATE STATE EMERGENCY MANAGEMENT COORDINATOR OR FEMA REGIONAL TRAINING MANAGER TO NETC. 24c. FOR FIELD PROGRAM COURSES, SUBMIT APPLICATION TO APPROPRIATE SPONSOR. 25. DISPOSITION U ACCEPTED U REJECTED SIGNATURE OF REVIEWER DATE EQUAL OPPORTUNITY STATEMENT NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, sex, 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 19764; and Section 504 of the Rehabilitation Act of 1973. PURPOSES: To determine eligibility for participation in NFA and EMI courses. Information such as age, sex, 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 Boards 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 volunteer 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. Information Regarding Disclosure of Your Social Security Number Under PL 93-579, Section 7(b) - E.O. 9397 authorizes the collection of the SSN. The SSN is necessary because of the large number of individuals who have identical names and birthdates and whose identities can only be distinguished by the SSN. The SSN is used for record-keeping purposes, i.e., to ensure that your academic record is maintained accurately. Disclosure of the SSN is voluntary. However, if you do not provide your SSN, another number will be substituted, which will delay processing of your application or course certificate. PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 9 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 the form. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right comer of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, U. S. Department of Homeland Security, Federal Emergency Management Agency 500 C Street, SW, Washington, DC 20472. NOTE: Do not send your completed form to this address. Please return it to the appropriate address shown in block 24. U.S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY GENERAL ADMISSIONS APPLICATION SECTION I - GENERAL INFORMATION 2. NAME (Last, First. Middle Initial, Suffix) Smith, David H. See Reverse for Privacy Act Statement O.M.B. No. 1660-0007 Expires February 28, 2007 1. U.S. Citizen ❑✓ YES ❑ NO If No, City and Country of Birth: 4. MAILING ADDRESS (Street, avenue, road no., city or town, state, and zip code) 551 CR 176 Georgetown, Texas 78628 9a. ENTER COURSE CODE AND TI TLE:(If you wish to apply for more than one course, please attach a sheet of paper to this application) Executive Leadership R125 3. SOCIAL SECURITY NO. 464-13-6245 5. WORK PHONE NO. (512) 218-3200 6. HOME PHONE NO. (512) 259-9563 7. FAX NO. (512) 218-5594 8. E-MAIL ADDRESS: dhsmith@round-rock.tx.us 9b. COURSE LOCATION NFA 9c. DATES REQUESTED (Please give three choices) 4/4/05 5/16/05 7/11/05 10. COMPLETE THE ITEM BELOW REGARDING THE PRE INSTITUTION -REQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING DEGREE/CERTIFICATE DATE EARNED COURSE/FIELD OF STUDY 11. DO YOU HAVE ANY DISABILITIES (Includin special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE AT NETC or MWEOC? NO ✓YES❑ (If yes, describe & indicate any special assistance required on a separate sheet) SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION 12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED Round Rock Fire Department 203 Commerce Blvd. Round Rock, TX 78664 12b. NFIR.S # (NFA STUDENTS ONLY) 13. CURRENT POSITION AND NUMBER OF YEARS IN POSITION Interim Fire Chief 4 months, prior BC (reclassifed from Capt.) for 10 14. CHECK THE BOX S BELOW THAT BEST DESCRIBE YOUR ORGANIZATION 14a. JURISDICTION 3. City/TownNillage 14b. ORGANIZATION 1. All Career 15. CURRENT STATUS 1. Paid Full -Time 16. Briefly describe your activities/responsibilities as they relate to the course for which you are.applyying and identify how you will use the information obtained from the course. Attach an organizational chart for the organization being represented, indicate your position. If you need more space, please attach a sheet to this application. See attachment Available for any of the above dates for this course or any of these 07/25/05, 8/22/05, 9/19/05. I will also pass on the stipend due to previous courses this past year. 17 . SELECT ONE ITEM IN EACH COLUMN THAT BEST DESCRIBES YOUR PRESI RELATES TO THE COURSE FOR WHICH YOU ARE APPLYING. ALSO ENTER THl 1. Management 17c. NUMBER OF YEARS OF EXPERIENCE 18. DATE OF BIRTH (Mo. Day, Yr.) 3/18/60 20a. ETHNICITY 1. ❑ HISPANIC or LATINO 2. Q NOT HISPANIC or LATINO 2. Administra 20b. RACE (Please check all th 1. ❑ AMERICAN INDIAN or Al 4. a WHITE 5. ❑ NA I IT FEMA Form 75-5, FEB 04 REPLACES ALL PREVIOUS EDITIONS Reset All Fields SECTION III - ENDORSEMENT AND CERTIFICATION 21a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (18 U.S.C. 1001). 21b. 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. 21c. Further, I understand that, National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC ), and the Noble Training Center (NTC) are not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis. 21d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTC. Failure to do so will result in denial of the ss,, _i -rt stipend, expulsion from the course, and possible barring from future National Fire Academy (NFA) and Emergency Management Institute (EMI) courses. SIGNATURE OF APPLICANT 22. APPROVAL BY THE HEAD "OF,'THE• SPQNScRING C RG. "By signing this application, I certify that my organization does not discriminate on•tllb b ' dis bility in providing educational opportunities for its employees." • Ge, CO or DATE Mu; belief, national origin, economic status, or 23. Additional endorsements for application tu.fhe Emergency Management Institute: 23 --NATURE AND DATE (State Office) 23b. SIGNATURE AND DATE ( FEMA Regional Office) 24a. FOR NFA REGIONAL DELIVERY COURSES AND COURSES DELIVERED AT EMMITSBURG, MD. SUBMIT APPLICATION TO: NATIONAL EMERGENCY TRAINING CENTER OFFICE OF ADMISSIONS, BLDG. I-216 16825 SOUTH SETON AVENUE EMMITSBURG, MD. 21727 24b. FOR EMI COURSES DELIVERED AT NETC, MWEOC, OR NTC SUBMIT APPLICATION THROUGH THE APPROPRIATE STATE EMERGENCY MANAGEMENT COORDINATOR OR FEMA REGIONAL TRAINING MANAGER TO NETC. 24c. FOR FIELD PROGRAM COURSES, SUBMIT APPLICATION TO APPROPRIATE SPONSOR 25. DISPOSITION I1 ACCEPTED n REJECTED SIGNATURE OF REVIEWER DATE EQUAL OPPORTUNITY STATEMENT NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, sex, 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 19764; and Section 504 of the Rehabilitation Act of 1973. PURPOSES: To determine eligibility for participation in NFA and EMI courses. Information such as age, sex, 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 Boards 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 volunteer 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. Information Regarding Disclosure of Your Social Security Number Under PL 93-579, Section 7(b) - E.O. 9397 authorizes the collection of the SSN. The SSN is necessary because of the large number of individuals who have identical names and birthdates and whose identities can only be distinguished by the SSN. The SSN is used for record-keeping purposes, i.e., to ensure that your academic record is maintained accurately. Disclosure of the SSN is voluntary. However, if you do not provide your SSN, another number will be substituted, which will delay processing of your application or course certificate. PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 9 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 the form. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, U. S. Department of Homeland Security, Federal Emergency Management Agency 500 C Street, SW, Washington, DC 20472. NOTE: Do not send your completed form to this address. Please return it to the appropriate address shown in block 24.