THE FAMILY HEALTH CARE DECISION ACT
REPLY FORM -- PLEASE RESPOND BY THURSDAY, DECEMBER 1, 2005.

Mail or fax to: Assembly Health Committee, Room 822 LOB, Albany, NY 12248; fax: 518-455-5939

box I plan to testify at the December 8, 2005 hearing on the Family Health Care Decision Act.

box I plan to attend, but not testify.

box I require assistance and/or handicapped accessibility information. Type of assistance required:





Name:

Title:

Organization (if applicable):

Address:

City/State/Zip:

Telephone:

Fax:

E-mail:

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