PUBLIC HEARING REPLY FORM

Persons wishing to present testimony at the public hearing on Electroconvulsive Therapy (ECT) are requested to complete this reply form as soon as possible and mail it to:

Carl Letson
Legislative Associate
Assembly Committee on Mental Health, Mental Retardation and
Developmental Disabilities
Room 522 - Capitol
Albany, New York 12248
(518) 455-4371
(518) 455-4693 (fax)

check box     I plan to attend the following public hearing on Electroconvulsive Therapy (ECT) to be conducted by the Assembly Committee on Mental Health, Mental Retardation and Developmental Disabilities on July 18, 2001.

check 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.

check box     I will address my remarks to the following subjects:

_____     _____________________________________

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check box     I do not plan to attend the above hearing.

check box     I would like to be added to the Committee mailing list for notices and reports.

check box     I would like to be removed from the Committee mailing list.

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

_________________________________________________________

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NAME:     ______________________________________________________

TITLE:     _______________________________________________________

ORGANIZATION:     _____________________________________________

ADDRESS:     ___________________________________________________

TELEPHONE:     _________________________________________________

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