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Full Name:

First Name*

Last Name*

Address:

Mailing Address*

City*

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Date of Birth:

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Month

Year

Contact Information:

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Issue*

Comments

Consent:

I hereby request that the office of Chak Au, Member of Parliament, assist me with the issue stated above.

For this purpose I authorize the office of the Member of Parliament Chak Au and/or his representatives to consult the necessary government departments or agencies on my behalf and for the government department/agency to release any and all information in my file to the Member of Parliament and his staff. MP Au and his representatives may use and share with government officials any and all personal information and documentation, including correspondence, which I have provided to him or his representatives to the extent necessary in their efforts to assist me.

I agree