PUBLIC HEARING REPLY FORM

Persons wishing to present testimony at the public hearing on Hispanic and Asian American Women and Suicide are requested to complete this reply form as soon as possible and mail it to:

Elana Marton
Associate Counsel
Assembly Committee on Mental Health, Mental Retardation and Developmental Disabilities
Room 522 - Capitol
Albany, New York 12248
Email: martone@assembly.state.ny.us
Phone: (518) 455-4371
Fax: (518) 455-4693


box I plan to attend the following public hearing on Hispanic and Asian American Women and Suicide to be conducted by the Assembly Committee on Mental Health, Mental Retardation and Developmental Disabilities, The Puerto Rican/Hispanic Task Force and The Task Force on Women's Issues on December 7th, 2006.

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.

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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 Committee mailing list for notices and reports.

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

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






NAME:

TITLE:

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ADDRESS:

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