roster by xiangpeng

VIEWS: 12 PAGES: 2

									                 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.

								
To top