AUTHORIZATION FOR RELEASE OF RECORDS
I, do hereby authorize any military organization, law enforcement agency, physician or other medical personnel, insurance agencies, banks and credit agencies, former and present employers, or other individuals to furnish to the Sharpsburg Fire Prevention Association (the “Department”) or its authorized agent all available information.
I hereby release any of the above from any and all civil or criminal liability whatsoever for providing this information.
(Electronic) By typing my name below, I certify the above statements to be true and correct to the best of my knowledge, and that this information can be used for the purpose of processing my Sharpsburg Fire Prevention Association, Inc. application. (Non-Electronic) If filling out the application by hand, please provide your original signature and date.