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Midland District Office
135 Ashman Dr.
Midland, MI 48640
Phone: (989) 631-2552
Fax: (989) 631-6271
Traverse City Office
121 E. Front St.
Suite 202
Traverse City, MI 49684
Phone: (231) 929-4711
Fax: (231) 929-4776
Washington D.C. Office
137 Cannon Building
Washington, DC 20515
Phone: (202) 225-3561
Fax: (202) 225-9679
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FULL NAME:__________________________________DATE OF BIRTH:____________
ADDRESS:______________________________________________________
PHONE: (H)_____________________ (O)_____________________SSN/TAX ID NUMBER:___________
TODAY'S DATE______________________SIGNATURE__________________________
PLEASE DESCRIBE THE NATURE OF YOUR CONCERN OR REQUEST:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
My signature on this page allows Congressman Dave Camp to contact appropriate officials, forward correspondence, discuss the matter, and receive pertinent information from local, state and federal agencies. It is my understanding that this form is being used in compliance with the Privacy Act of 1974.
I authorize the ______________________________(Name of Agency) to release the necessary information regarding my case to Congressman Dave Camp and permit the third-party named below to receive information regarding my situation from my Representative.
Third-Party (optional - person you designate, other than yourself, to give and receive information pertaining to your situation):
NAME/ADDRESS/PHONE:___________________________________________
Please return form to: Congressman Dave Camp
135 Ashman Street
Midland, Michigan 48640
FAX: 989-631-6271 |
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