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I hereby authorize the Third Legislative District – Sen. Burzichelli, Asw. Simmons, and Asm. Bailey, Jr. and/or their staff to request and receive information from the appropriate state agency or department in reference to my inquiry. This authorization includes written correspondence, telephonic, or any other means of communication. The state agency or department is authorized to furnish copies of any documents, correspondence, or information relative to my inquiry until the matter is resolved.
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I am asking LEGISLATORS to intercede on my behalf. I request that you or a member of your staff review my concerns as outlined above. I understand that this form is being used in compliance with the Freedom of Information Act and the Privacy Act of 1974. I hereby declare under penalty of perjury that I am currently a resident of the State of New Jersey and that the information contained in this release is truthful and complete to the best of my knowledge.
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