Congressional Certificates

If you would like to request a Congressional Certificate for someone living in the 12th Congressional District please complete and submit the request form below with the requisite information.

Congressional Certificates often highlight occasions including:

Scholarship Achievement
Academic Achievement
Sports Accomplishment
Business Milestone
Community Achievement
Other Accomplishments and Achievements of Public Distinction

Current Certificate Request Form
Complete

Indicates required field

Date request is submitted

Date of event

Date certificate is needed by

Number of certificates needed

Certificate Recipient

Prefix:

First Name:

MI:

Last Name:

Suffix:

Purpose or recognition reason

Point of Contact Information

Prefix:

First Name:

MI:

Last Name:

Suffix:

Email Address

Phone Number

Phone Type:

What are these options?

Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option 'Voice' is a standard audible telephone.

How would you like to receive the certificate?

Pick up

Mail

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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