Developing a Primary Care Agenda Public Hearing Reply Form -- Respond by Tues., Oct. 23rd

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


box I plan to testify at the __ [October 29/Albany] __ [November 2/NYC] hearing.

box I plan to attend, but not testify at, the __ [October 29/Albany] __ [November 2/NYC] hearing.

box

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




NAME:

TITLE:

ORGANIZATION:

ADDRESS:

E-MAIL:

TELEPHONE:

FAX TELEPHONE:
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