MERRELL INSTITUTE ~ Bill C. Merrell, Ph.D.- 631-563-7720

                                    In order to help you, and see what we can go to help, we need to know the facts:

Name___________________________________________________  Tele. #_________________________________________

Address_________________________________________________________________________________________________

What happened?__________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

What your Name, company name or signature used without your permission?________________________________________

________________________________________________________________________________________________________

Do you know who used your name?  [  ] Yes  [  ] No  [  ] Unsure  Person who used your name____________________________

Do you know anything about this individual?___________________  His/Her Telephone #______________________________

His/Her Address__________________________________________________________________________________________

Have you filed a Police Report?_______________ If Yes, When and Where, If No, Why?_______________________________

_________________________________________________________________________________________________________

Are you willing to file a Police Report? [  ] Yes  [  ] No  If yes, please indicate who you will report the incident to and what doc-

uments you will submit to the police____________________________________________________________________________

_________________________________________________________________________________________________________

Have You Filed a Report With the Dept of State?___________ If Not, will you?________________________________________

Do you have any witnesses, documents or statements which will assist us in helping you?________________________________

_________________________________________________________________________________________________________

Is there a NYS, Dept. of State Hearing?__________________ Date/Location/Time_____________________________________

Do you have legal counsel?______________ Attorney/telephone/fax_________________________________________________

Do you wish us to research your case, at no obligation to you, and contact you or your attorney on this case?________________

If you believe we can help, we will ask to a fee to reimburse us for time and expenses. We will be able to determine the approx.

cost once we initially investigate your case.  Your information will remain confidential with us.

Signed________________________________________________________________________ Dated______________________

Mail to:     Merrell Institute: 1461 Lakeland Ave., Suite 17, Bohemia, NY 11716  Questions? Call us at 631-563-7720

                  Bill Merrell will be reviewing your case personally and determine if we can assist your case.


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