PAIN MANAGEMENT LEGISLATION HEARING
REPLY FORM-PLEASE RESPOND BY THURSDAY, OCTOBER 28, 2004

Mail to:        Assembly Health Committee , Rm. 822 Leg. Office Bldg., Albany, NY, 12248
Or fax to:    518-455-5939


[   ] I plan to testify at the November 5, 2004 Hearing on Pain Management Legislation, NYC.

[   ] I plan to attend, but not testify at the November 5, 2004 NYC Hearing.

[   ] I will require assistance and/or handicapped accessibility information. Please specify type of assistance required:



Name:

Title:

Organization (if any):

Address:

City/State/Zip:

Telephone:

Fax:

E-mail:

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