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.
take me back to the original site: www.nysappraiseradvocate.com