Purpose of this form:

Use this form to specify the names and client numbers of the women you want to contact as well as the contact information you authorize for release to those women.  Please be sure to provide all necessary information.  Incomplete forms will not be processed.

Please confirm your identity:
Name
Client number  (8 digits only)
Address
Date of birth (yr/mo/day)          
If you have not already done so, click here to fill out your "Contact Information for Release Authorization Form."
Requests:

Use the form below to request to contact up to 10 women.  (If you want to request to contact more than 10 women, come back and fill out the form again after submitting your first 10 requests.)  When you request to contact women, you do so subject to the following terms:

You hereby agree to hold harmless and release TMA from all legal liabilities resulting from:  1. Your consent to TMA to facilitate contact between you and the women indicated below.  2. Your consent to the release of your personal contact information by TMA to the women indicated below.  3. Any future conduct by you or the women.

You understand that TMA services are provided subject to the terms of the TMA Agency Agreement.
 
1. Woman's name    Client#  (8 digits)
2. Woman's name    Client#  (8 digits)
3. Woman's name    Client#  (8 digits)
4. Woman's name    Client#  (8 digits)
5. Woman's name    Client#  (8 digits)
6. Woman's name    Client#  (8 digits)
7. Woman's name    Client#  (8 digits)
8. Woman's name    Client#  (8 digits)
9. Woman's name    Client#  (8 digits)
10. Woman's name    Client#  (8 digits)