Your Representative

USE OF A REPRESENTATIVE

5. Your representative's full name Family name (Surname) Given name(s) 6. Your representative (tick one box): (i) is UNCOMPENSATED and is a friend or family member member of the College of Immigration and Citizenship Consultants (CICC), a Canadian provincial or territorial law society, or the Chambre des notaires du Québec other (please specify)

  Your, Representative, Use of a representative, Your representative

APPOINTMENT OF REPRESENTATIVE

representative may do, on the back of the "Claimant's Copy" of this form. If your representative has your permission to designate an associate, such as a clerk, other party, or entity, such as a copying service, to receive information for him or her from us about your claim(s), check the block to authorize this release.

  Your, Representative, Your representative

We are committed to the privacy of your health information ...

Appointment of an Authorized Representative You have the right to appoint an authorized representative to act on your behalf with the Department. If you want to name a person or organization as your authorized representative, use this form. We are committed to the privacy of your health information. Please read this form carefully.

  Your, Representative

Distric Name t Party WorkPhone HomePhone Room Address ...

Name Distric t Party WorkPhone HomePhone Room Address Counties Office Email Shane Aguirre 17 Rep 102-C 709 Highland Circle Tupelo, MS 38804 Lee (601) 359-3374 saguirre@house.ms.gov