e-..e> RGFOGED 'PO OWE I PeRriellaQ I r..)C-5..`...) PLAN • 1. Name mcn—tv 2. Date of Bkth 3. "-Address RE...cit9espi tJC..., FUNS r\I — MeDtc. Ev. / / I the above named person authorise Geoff Brock MP, Member for Frome and his staff to make enquiries on my behalf regarding my represent