PUBLIC HEARING REPLY FORM

Persons wishing to present testimony at the public hearing on the merger of the New York State Banking Department and the New York State Insurance Department are requested to complete this reply form as soon as possible and mail, email or fax it to:

Najay Roache
Analyst
Assembly Committee on Insurance
Room 442 - Capitol
Albany, New York 12248
Email: roachen@assembly.state.ny.us
Phone: (518) 455-4311
Fax: (518) 455-7095
box
I plan to attend the following public hearing on the merger of the New York State Banking Department and the New York State Insurance Department to be conducted by the Assembly Committees on Insurance, Banks and Oversight, Analysis and Investigation on Thursday, December 1, 2011.
box
I plan to make a public statement at the hearing. My statement will be limited to 10 minutes, and I will answer any questions which may arise. I will provide 10 copies of my prepared statement.
box
I will address my remarks to the following subjects:


box
I do not plan to attend the above hearing.
box
I would like to be added to the Committees' mailing list for notices and reports.
box
I would like to be removed from the Committees' mailing list.
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: