Participant Enrollment Application Form

Participant Enrollment Application Form

Privacy Act Statement (Public Law 93 579)

This is an electronic form, DO NOT print and mail. Complete Required Information on the form then submit.
Field marked * is a required field.

Required Student Information

Instruction: With mouse, point and click on data entry box. Use tab key to advance from box to box. Use mouse and scroll bar to move through the form.

Please enter your social security number below in the format shown. EMI will use this entry as your unique student identification number.

Without an accurate number, your enrollment processing will be delayed. If you prefer not to disclose your SSN, you must request a student identification number before enrolling or submitting an exam. To request a student ID, print this form, complete it, and mail it to the address on this screen. You may also fax your request to the Independent Study Office at 301-447-1201. You must include a written request for a student ID, as well as proof of U.S. citizenship by providing a photocopy of your; passport, voters registration card or birth certificate. Please include your email address to expedite student ID delivery.

* Social Security Number: Format is ###-##-####.
Please click on the Transaction Security link to see how we secure your information on this page.

* Re-enter your Social Security Number: Format is ###-##-####.

Please enter your LAST NAME in the field below.

We cannot accept your application without a complete name and mailing address. Please use the same last name for all enrollments to speed application processing.

* Last Name: Suffix: (Jr., Sr., PhD., III, etc.)

* First Name:

Middle Initial:

* Email Address: Enter a valid email address.

* Re-enter Email Address:

* Mailing Address:

Bldg / Suite / Apartment (if needed):

* City: * State:

* Postal Zip Code: Format is ##### or #####-####.
Note: If you are unsure of the zip code plus four, please use this link from the United States Postal Service to find it or try this link from National Association of Counties.

Select Business/Organization:

Work Telephone Number: () -

Home Telephone Number: () -

* Course ID:

It is essential that you complete all requested information since it will be electronically transferred to the independent study database for processing. Please retain a copy of your answers, until you receive an email notice confirming a successful course completion--this will allow you to resubmit your exam in the event of submission errors or network problems. Thank you.

This Web site can secure your private information using a VeriSign SSL Certificate. Information exchanged with any address beginning with https is encrypted using SSL before transmission. This is an electronic version of FEMA Form 95-23 which expires on September 30, 2005. The OMB Number is 3067-0277.

An official web site of the Department of Homeland Security and the Federal Emergency Management Agency
Emergency Management Institute, 16825 S. Seton Ave., Emmitsburg, MD 21727