Fillable Privacy Release And Constituent Information Form printable pdf download

Privacy Release And Constituent Information Form

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1015 N. Broadway Ave., Suite 300 • Oklahoma City, OK 73102 • Phone: (405) 231-4941 • Fax: (405) 231-5051

5810 E. Skelly Dr., Suite 1000 • Tulsa, OK 74135 • Phone: (918) 581-7651 • Fax: (918) 581-6332

PRIVACY RELEASE and CONSTITUENT INFORMATION FORM

Pursuant to Public Law 93-579, the Privacy Act, I hereby authorize Senator James Lankford and/or his staff to request and receive information from the appropriate

federal agency or department in reference to my inquiry. This authorization includes written correspondence, telephonic, or any other means of communication. The

federal agency or department is authorized to furnish copies of any documents, correspondence, or information relative to my inquiry until the matter is resolved.

Name: ____________________________________________________________________________________________

FIRST

MIDDLE

LAST

Address: __________________________________________________________________________________________

City ______________________________________________ State _________ ZIP code __________________

Date of birth: __________________________Social Security Number: ________________________________

Telephone: Home ________________________________________ Work ______________________________________

Fax __________________________________________ Cell ______________________________________

Email: ____________________________________________________________________________________________

CASE INFORMATION

Briefly explain the problem and attach copies of any relevant documentation. (

Use additional paper if more space is needed.)

Has another Congressional or Senate office been contacted regarding this issue? Yes _____ No _____

If yes, please list the office: ___________________________________________________________________________

I hereby declare that I am currently a resident of the State of Oklahoma and that the information contained in this release is truthful and complete

to the best of my knowledge. *If you are signing on behalf of another, please provide a copy of your authority to do so (Power of Attorney, etc.).

Handwritten signature or mark: _________________________________________ Date: _________________________

Printed name: _______________________________________________________

PERMISSION: You have my permission to discuss my case with the following person(s): ___________________________

__________________________________________________________________________________________________

Please proceed to page 2 of this document.

Privacy Release And Constituent Information Form

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