Public Testimony Registration

Name *

Company or Organization *

Business Address *

Business Address 2

Business City *

Business State *

Zip Code *

Zip Plus -

Zip Note

E-mail *

(ex: username@domain.com)

Telephone Area Code * /

Telephone Prefix * -

Telephone Line Number *

Telephone Extension x

(ex: 800/555-1234)

Fax Area Code /

Fax Prefix

Fax Line Number -

Fax Extension x

Preferred Confirmation *

Mailing Address

Facsimile

Representation

Check here if you are representing or speaking on behalf of any company / organization.

If yes, name company

Affiliation

Check here if you are a private practice physician not affiliated with any manufacturer / organization.

Summary of Testimony *