EmailMe Form - Authorization to Release Fire Incident Information

Authorization to Release Fire Incident Information

By signing below you agree....

I understand that information used or disclosed pursuant to this report could be subject to re-disclosure by the recipient and if so, may not be subject to federal or state law protecting its confidentiality.

I understand that by requesting this release of the incident records, I also release the Gaffney Fire Department from all legal responsibility or liability that may arise from the release of these records.

Requesting Party *
First Last
Requesting Party Email Address *
Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Date of Incident *
MM / DD / YYYY
Incident Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Incident Type (Building Fire, Vehicle Fire, Etc) *
Reason for Request
How would you like to receive the records
US Mail
Email
Signature
Clear
You can sign with your computer mouse or finger on a phone or touch screen.

EMF Form Builder

Report Abuse