Congressman Eric Burlison Privacy Act Release Statement

Congressman Eric Burlison Privacy Release Statement
As mandated by the 1974 Privacy Act, I authorize Congressman Eric Burlison and his staff to make inquiries on my behalf and to obtain information from my personal records or files regarding the problem mentioned below. I certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy release and submitted with it; 3) all of this information is complete, true, and correct.
Signature

Clear
Date

MonthDayYear
Date
Signature of parent or guardian if different than the person requesting information

Clear
Date

MonthDayYear
Date
Personal Information: (Please print or write legibly)
First
Middle
Last
Address

Address

Street Address Line 2

CityState / Province

ZipCounty
Home or Cell Telephone
Format: (000) 000-0000.
Work Telephone
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Social Security Number
Agency to contact if known
Description of Issue
This form will be received by Veterans and Military Coalition of the Ozarks, Ed Wilson 417-676-0196 or Dub White 417-699-8145, and will be submitted to Congressman Eric Burlison's office after reviewed for accuracy.
Should be Empty:

Congressman Eric Burlison Privacy Release Statement