Request for Meeting with Philip Donato MP

Please complete the form below or click here to download the form and return to our office via email or post.

DISCLOSURE

Please be advised that when your State Member makes representation on your behalf, their office and staff may have to disclose your correspondence and personal details to the relevant department or Minister to obtain an appropriate response. Please indicate if you do not want your details to appear in correspondence. If you do not wish to disclose your personal details, please be aware a full representation of your concerns may not occur.

By completing and submitting the below form you are giving permission for your details and/or correspondence to be passed onto relevant persons in representations made by the office of Mr Philip Donato, MP in his capacity as State Member for Orange

Due to the nature and confidentiality of the meeting, it is an offence, under the Surveillance Device Act 2007-Section 7, to knowingly record conversations between your State Member and the constituent. If you possess a device with the capability to record the conversation you must disclose this prior to the conversation.

Name

Organisation/Group

Address

Phone

Email Address

Number of people attending the meeting (max. 5 people)

Names and details of other people attending the meeting

Issues/Concern Summary

What actions, if any, have been taken to resolve the issue previously (please attach documents of relevance, or list names and contact details of Department/Organisation):

Desired outcomes: i.e. what would you like to see occur or what assistance do you require from the Member?

Please confirm if you intend to use any device to record the conversation between myself and my State Member, Mr Philip Donato, MP. Please confirm if you intend to use any device to record the conversation between myself and my State Member, Mr Philip Donato, MP. Yes, I intend to use a device to record the meeting. No, I won't be recording the meeting.