Before Senator Dole can make inquiries on your behalf, many federal agencies require that you send us a signed copy of the Privacy Act Waiver. Please fill out the information below, then manually fill out the Social Security number and signature fields before mailing or faxing to Senator Dole's office.

Please note: this form is for printing only; this information will not be transferred by email or into a database.
Full Name:
Email Address:
Address 1:
Address 2:
City:		Zip Code:
Telephone:
County:
Date of Birth:
Federal Agency Involved:
Please complete the following fields if applicable to your request.
Veteran's Claim Number:
Military Branch of Service:
Rank:
Alien Registration Number:
Medicare Number:
OWCP Number:
CSA Number:
Service Number:
Unit:
Dates of Service:
If you are requesting assistance on behalf of a family member, please provide that person's name. Please be aware that Senator Dole can only act with that person's permission.
Family Member Name:
If you have contacted another congressional office regarding this issue, please list the office.
Other Office:
Detailed Description of Problem: