Ben Jessome
MLA, Hammonds Plains-Lucasville
I also consent to Ben Jessome, MLA for Hammonds Plains-Lucasville and his staff using my personal information until the matter is resolved or until I revoke this consent.
Your personal information, whether on paper or in electronic form, will only be used for the purpose of resolving this specific issue. The information will be stored securely and will only be accessed by authorized staff. The records will be destroyed per our document retention and secure destruction policy at a future point.
This form will not be processed without a signature. The electronic signature can be added using your finger or a stylus on a touchscreen device or with your mouse on a computer.
Your electronic signature is legally binding, just as a written signature granted in person.
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