. RELEASE OF INFORMATION Hon Geoff Brock MP, State Member for Electorate of Frome PCFOSE 0 1V GET 1NNOt_ve—D REFUGE-a —Cs Cr tie• r4P-04401-tor\I AECI9epr FONID I rJ — t460 c c. IS VS t kat) pi_423N Name / / 2. Date of Birth 3. Address I the above named person authorise Geoff Brock MP, Memb