Health Care Reform Act Public Hearing Reply Form - Respond by February 10, 2005


Mail to: Dick Gottfried, 822 LOB, Albany, NY 12248
Or fax to: 518-455-5939

Square I plan to testify at the February 16 Albany hearing.

Square I plan to attend, but not testify at, the February 16 Albany hearing.

Square I plan to testify at the February 18 New York City hearing.

Square I plan to attend, but not testify at, the February 18 New York City hearing.

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


Name:

Title (if applicable):

Organization (if any):

Address:

City/State/Zip:

Telephone/Fax:

E-mail:
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