Notice of Designation of Representative

• Legal Form Number: 1.07a
• Section: Office of Congressional Workplace Rights (United States)

OCWR ADR Form 3



John Adams Building, 110 Second Street SE, Room LA-200 | Washington, DC 20540-1999 | (202) 724-9250 (O) | ocwr.gov

Revised June 2024

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



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I

I

Your name: ________________________________________________________________ ___________

 with OCWR 

_____________ ____________________________

bwas :

__________________________________________________________________________ ___________

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

              -

:

 your  _________

If your  

is 

__________________________________________________________________________ ___________

Phone number: ________________________________________________________________________

Email: ____________________________________________________________________ ___________

Mailing address: _______________________________________________________________________

__________________________________________________________________________ ___________

______________________________________________________________________ _____________

*

*If your representave is an aorney, they may sign this form on your behalf.