Supporting Our Heroes of Central Pennsylvania 
REQUEST FOR HELP APPLICATION
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First and Last Name *
Full Mailing Address *
Contact Number *
Email Address *
Are you a First Responder?  *
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Please write your affiliation, company or department: *
Who is your chief/supervisor? (May be verified) *
What county is your company or department located in?
Explain your situation/need... *
Do you have any additional relevant information that you would like to share? *

Disclaimer & Client Consent for Assistance Request

By signing below, I, the undersigned, acknowledge and agree to the following:

1. Contingent Approval: I understand that any assistance or support provided by Supporting Our Heroes of Central Pennsylvania is contingent upon approval by the organization's voting members.

2. Verification Requirement: I may be asked to submit verification documents as part of the approval process to substantiate my request for assistance.

3. Confidentiality: I understand that any personal information I provide will be kept confidential and used solely for the purpose of processing my request for support.

4. No Guarantee of Assistance: While Supporting Our Heroes of Central Pennsylvania will make reasonable efforts to assist, I understand that no guarantee of assistance or funding is being made at this time.

By signing below, I consent to the collection and use of my information for the purpose of processing my request and confirm that the information I have provided is accurate to the best of my knowledge.


By typing your name below, it will act as your signature. 

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