Home   /   Privacy Authorization Form
 

Privacy Authorization Form

  First Name:
  Last Name:
  Address:
City: 
State:
Zip:
If you do not know your four digit extension for your zip code, please check the U.S. Postal Service web site for more information.
Home Phone: 
Work Phone: 
Email: 
Social Security #: 
Medicare #:
Date of Birth: 


PLEASE EXPLAIN YOUR PROBLEM IN THE MESSAGE BOX BELOW

 
I authorize Congresswoman Ginny Brown-Waite and her staff to contact appropriate agencies on my behalf. This is to comply with the Privacy Act of 1974, which provides that as of September 27, 1975, disclosures of information of a personal or confidential nature will no longer be permitted to third parties without the written consent of the individual involved.


Veterans
Ginny is working hard for Florida's Veterans.
Social Security
Learn More About Preserving and Strengthening Social Security
Health Care &
    Prescription Drugs
Learn More About Health Care and Prescription Drugs 

Tele-Scare
Learn the truth about the misleading tele-scare calls that invade your privacy.
 
Vist Washington

© 2005 Congresswoman Ginny Brown-Waite. All Rights Reserved.