Class Number: Class Name: Code Name: Date: Location of Training: Total Hours: Total Attending Class: (Department) (Mailing Address) (Phone Number) Description of Training: Training Aids: Remarks: SFMO Forestry Practical NFA Other Please check the boxes that apply. Instructor: Phone Number: Signature: Date: Instructor: Phone Number: Signature: Date: ETHNICAL/RACIAL ORIGIN STATUS *Please enter appropriate SEX American Indian or Alaskan Native Asian (Oriental & Pacific Islander) Paid Full-time Paid Part-time abbreviation/number M = Male F = Female Black White Hispanic Volunteer Please Print Information *Eth/ *Status Racial Pass/ *Sex Full Name Soc. Sec. No. Department/Agency Fire Dept Address City State Zip Code Origin Signature Fail 1 2 3 4 5 6 7 8 9 10 11 12 13 ETHNICAL/RACIAL ORIGIN STATUS *Please enter appropriate SEX American Indian or Alaskan Native Asian (Oriental & Pacific Islander) Paid Full-time Paid Part-time abbreviation/number M = Male F = Female Black White Hispanic Volunteer Please Print Information *Eth/ *Status Racial Pass/ *Sex Full Name Soc. Sec. No. Department/Agency Fire Dept Address City State Zip Code Origin Signature Fail 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 PRIVACY ACT INFORMATION GENERAL. This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals applying for EFFECTS OF NONDISCLOSURE. Personal information provided on this form is given on a voluntary basis as is participation in any training admission to the National Fire Academy. program. Failure to provide this information will not affect your acceptance in the courses. AUTHORITY. Public Law 93-498, 15 U.S.C. 301, 44 U.S.C. 3101, 50 U.S.C. App. 2253, E.O. 12127 and E.O. 1214 Information regarding disclosure of your Social Security Number PL93-579, Section 7(b)-Solicitation of the social security number is authorized under provisions of E.O 9397, dated November 22, 1943. This disclosure of your social security number is voluntary and is only for PURPOSES AND USES. The principle purpose of the information requested on this form is to provide some basic common information on each recordkeeping purposes. If you do not provide your social security number, a number will be assigned to you for recordkeeping purposes. The participant in a field program course for inclusion in the student recordkeeping system maintained at the National Emergency Training Center social security number is used as an identifier to match the person completing the training with the correct master record in order to better assist resident and field courses and a copy of this record can be provided to a graduate upon written request. Information such as age, sex, and ancestral you in obtaining certifications of completed courses. The use of the social security number is necessary because of the large number of individuals heritage are used for statistical purposes only and will not affect participation in the course. Certain information may be released to Members of who have identical names and birth dates, and whose identities can only be distinguished by the social security number. the Board of Visitors for the purpose of evaluating the participants of the course; to States to update statistics of the National Emergency Training Center graduates assigned to their State or local jurisdiction; to a Member of Congress in response to an inquiry made at your request. Information will only be used or released as permitted by law.
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