Form 50-708 - Information Change For Arbitrator Registry

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Information Change for Arbitrator Registry

Information on this form and all attachments are subject to disclosure under the Texas Public Information Act.

All or part of this information will be published in the Registry of Arbitrators

or posted on a website available to the public.

Each person who is listed as an arbitrator in the Comptroller’s registry must report to the comptroller in writing any material change

in the information provided in the application within 30 calendar days of the change.

Failure of the arbitrator to report a material change may result in the removal of the arbitrator from the current registry.

For Assistance - If you have any questions about this application, contact the Texas State Comptroller’s office at 1-800-252-9121.

The local number in Austin is 512-305-9999. The email address is: ptad.cpa@cpa.state.tx.us.

Americans with Disabilities Act - In compliance with the Americans with Disabilities Act, this document may be requested in

alternative formats by calling 1-800-252-9121.

Federal Privacy Act - Disclosure of your Social Security number is required and authorized under law, for the purpose of tax

administration and identification of any individual affected by applicable law. 42 U.S.C. §405(c)(2)(C)(i); Tex. Govt. Code §§403.011 and

403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act,

Chapter 552, Tex. Govt. Code, and applicable federal law.

Public Information Act - Section 552.147, Tex. Govt. Code, excepts Social Security numbers from disclosure. If this form is

requested as public information, your Social Security number will not be released.

You have certain rights under Chapters 552 and 559, Tex. Govt. Code, to review, request and correct information we have on file about you.

• Type or print in black ink.

• Do NOT write in shaded areas.

1. Taxpayer number for reporting any Texas tax OR

Texas Identification Number if you now have or have ever had one .......................................................................

2. Social Security number* (REQUIRED) .........................................................................................................................

* Your Social Security number is not subject to public disclosure according to Section 552.147, Tex. Govt. Code.

3. Individual’s first name, middle initial, last name, suffix (i.e., Jr., III, etc.)

First name

M.I.

Last name

Suffix

4. Mailing address, city, state, ZIP code with extension

Street number, P.O. Box, or rural route and box number

City

State/province

ZIP code

County (or country, if outside the U.S.)

Phone number

5. Daytime phone number ...................................................................................................................................

6. Email address* ................................

*Your email address is confidential according to Section 552.137, Tex. Govt. Code; however, by including the email address on this form,

you are affirmatively consenting to its release under the Public Information Act.

FAX number

7. FAX number (optional) ....................................................................................................................................

8. Physical location

Street number or rural route and box number (Do NOT use P.O. Box)

City

State/province

ZIP code

County (or country, if outside the U.S.)

50-708-1 (Rev.7-13/5)