Allegany County Office of Emergency Management
Photo Accountability ID
Fire/EMS Department Name:
*
ID Tag Color
*
Please Select
Red (Interior Firefighter)
Yellow (Exterior Firefighter)
Blue (Emergency Medical Services Only)
White (Fire Police & Auxiliary)
White (MTS Employees)
Please select one option
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
NY Student ID#
EMS ID #
Rank
Height
*
Weight
Eye Color
*
Hair
*
Race
*
Please Select
American Indian
Asian
Black/African American
Hispanic/Latino
White
Prefer not to answer
Sex
*
Please Select
Male
Female
Prefer not to answer
List of Qualifications
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Hire Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Commision Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date (Example EMT Card)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: