FEDERAL EMERGENCY MANAGEMENT AGENCY

OMB No. 3067-0024 Expires

Emergency Response to Terrorism: SeFStudy See Other Side for Privacy Act Statement
September 30, 999
Application Form and Answer Sheet
You are not required to respond to this collection information unless a valid OMB control number appears in the upper right comer of this form.
SECTION I: General Information I
I. U.S. Citizen % y e s P No If No, Place o f Birth:
2. PLEASE PRINT YOUR NAME (As you would 3. DATE OF BIRTH 4. SOCIAL SECURITY NO. 5. SEX
like it to appear on your certificate.) (Mo., Day, Yr.)
5$1-1'1-bO00
L\fl r\ihf~\e 5 9/5/1992 E%e
Last First Middle Initial
6. HOME ADDRESS (Street, avenue, road no., P.O. Box, city or townlstate and zip code) 7. HOME PHONE NO.
(219 ~141-7 \ %Zc
1107 Mlrlewp ).\i\\, 5~ AnWnla, 7%'t0~5b
8. PLEASE CHECK THE RACEINATIONAL ORIGIN WHICH BEST APPLIES T O YOU AND YOUR ANCESTRAL HERITAGE (Providing this
information is voluntary)

1. P AMERICAN INDIAN or ALASKAN NATIVE 3. P BLACK, not of Hispanic origin 5. P Hispanic

2. & ASIAN or PACIFIC ISLANDER 4. O WHITE, not of Hispanic origin
SECTION 11: EMPLOYMENT INFORMATION
9. NAME AND COMPLETE ADDRESS O F ORGANIZATION BEING 10. CURRENT POSITION AND NUMBER OF YEARS IN
REPRESENTED POSII'ION

NlA ~5hJ3u7~3

I I . CHECK THE BOX(ES) THAT BEST DESCRIBE YOUR ORGANIZATION:

I la. JURISDICTION I l b. ORGANIZATION
1. O STATEWIDE 4. P SPECIAL DISTRICT~OWNSHIP 7. 9 FOREIGN 1. O ALLCAREER
2. 0 COUNTYGOVERNMENT 5. O FEDERAUMILITARY 8. O FEMA 2. O ALLVOLUNTEER
3. 0 CITYITOWNNILLAGE 6. P INDUSTRYBUSINESS 9. O NDERAMA 3. O COMBINATION
12. CURRENT STATUS 1. D PAID FULLTIME 2. P PAID PARTTIME 3. 0 VOLUNTEER
13. SIGNATURE O F APPLICANT DATE:
l r . ~ ~ c 1r /0
14. 1 hereby certify, a s chief officer o r supervisor of the above individual, that helshe is a member of the named departmentlagency, and has completed the
ERT:SS course and examination according to instructions.

FINAL EXAM ANSWER SHEET: PLEASE COMPLETELY FILL IN YOUR ANSWER CHOICE:

a b c d
1 . b D D D
2. D m D
3. I D O D
4. I D D O
5 . 1 D D
6.' 1 D O O
7 . 1 D O D
8 . 1 D D
9. D I D O
10. m D D 0