Document ZB9E7NJVX7j2MpQZxvrB9yjq7
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Office of Representative Julie Johnson Digital Privacy Release Form
Complete the form below to request help with a Federal Agency. When complete, click Submit to send to our office for assistance.
Fields marked with * are required
Please Provide Applicable Identifying Information
Agency Involved Department of Transportation
Prefix
First Name
(b)(6)
MI Last Name
Social Security Number DOB
b)(6)
Email Address
b)(6)
Phone Number
(b)(6)
Address Line 1
(b)(6)
Address Line 2
City Richardson
Agency Case Number PI # 2120850
Mortgage Loan Number Rank Military Rank
N/A
N/A
State Zip Code TX 75081
Have you contacted any other elected official regarding this case? No
If Yes, Officials Name?
Please explain the problem and the resolution/outcome you are seeking:
Sierra Club v. Dept. of Transp. - 3:25-cv-06221
SC_EVERSPLIT0018991
The FAA has revoked my medical (b)(6)
(b)(6)
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Constituent Authorization
To be able to assist you, we must have a signed privacy release form that clearly outlines your problem and the remedy you are seeking. By checking the box below you are giving our office permission to look into the matter on your behalf. Please make sure to attach below any relevant identifying information and supporting documents which relate to your inquiry.
g I hereby request the assistance of the Office of Representative Julie Johnson to resolve the matter described below. I authorize the Office of Representative Julie Johnson to receive any information that they might need to provide this assistance. The information I have provided to the Office of Representative Julie Johnson is true and accurate to the best of my knowledge and belief. The assistance I have requested from the Office of Representative Julie Johnson is in no way an attempt to evade or violate any federal, state, or local law. Date/Time 3/6/2025 8:42:12 AM
* Signature
(b)(6)
Sierra Club v. Dept. of Transp. - 3:25-cv-06221
SC_EVERSPLIT0018992