A Member of Congress will not disclose your e-mail address or any other contact information you have provided to us. We will not provide your contact information to any other organization unless you specifically authorize us to do so.
AUTHORIZATION FORM
The Honorable Patrick J. Tiberi
3000 Corporate Exchange Drive
Suite 310
Columbus, Ohio 43231
(614) 523-2555
I hereby request Congressman Tiberi's assistance and authorize, under the Privacy
Act of 1974, the release of any and all information necessary on my behalf.
Signature____________________________________ Date_______________
Name (please print)_______________________________________________
Address_________________________________________________________
_________________________________________________________
Telephone (home)____________________ (work)_______________________
Cell Phone _______________________ EMAIL__________________________
Social Security #__________________________________________________
Veterans Administration Claim#_____________________________________
Service #_________________________________________________________
Other #__________________________________________________________
Date of Birth ____________________________________________________
In the space provided below, please state the nature of the problem for which you
are requesting Congressman Tiberi's assistance.
(Use additional paper if necessary)
