Remote-friendly Administrative Assistant / Data Entry Candidate

Privacy Release Form

US Representative Ralph Norman

South Carolina – 5th District

Dear Congressman Norman:

I give you permission to investigate my difficulties with:

(Name of federal agency or issue)

I understand that this form is being used in compliance with the Privacy Act of 1974. Please print and fill in: Date: Name Signature: Address: City State ZIP Daytime Phone Fax Number (if available) Email (if available) Social Security Number Date of Birth Briefly explain the nature of the problem: (You may also use the back.) Please return the form and all supporting documents to Congressman Ralph Norman either by email or at the South Carolina District Office located at 516 Oakland Ave. Rock Hill, SC 29730 Rock Hill, SC 29730

* Phone number - 803-***-**** * Fax - 803-***-****