PAIN MANAGEMENT LEGISLATION HEARING
REPLY FORM-PLEASE RESPOND BY TUESDAY, JANUARY 18, 2005

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


box I plan to testify at the January 26, 2005 Hearing on Pain Management.

box I plan to attend, but not testify at the January 26 Hearing on Pain Management.

box

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:

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