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A Declaration of Life by Pro-Life Physicians: Signature Page

This declaration was created by the public policy department of of American Life League, Inc. It was circulated to members of the medical and scientific communities for review and endorsement. If you agree with the Declaration of Life and want to publicly support it, please print this page, then sign and return the statement below to:

Judie Brown
American Life League, Inc.
P.O. Box 1350
Stafford, VA 22555

I agree with the Declaration of Life. You have my permission to add my name as a supporter of the document and to use my name in news releases and other avenues dealing with the publication and promotion of this document.

Signed:________________________________________________

PLEASE PRINT BELOW:

Name:_________________________________________________

Specialty and Credentials:__________________________________

______________________________________________________

Address:_______________________________________________

City/State/Zip:___________________________________________

Phone#:________________________________________________

Fax #:_________________________________________________

E-Mail Address:_________________________________________

I belong to the following category/categories:

___Physician 
___College Professor 
___Scientist 
___Nurse 
___Health Care Professional 
___Other_______________