Aesculapius Awards
Fax response form to 301-320-0978 — page 1 of _____

Name:

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Title:

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Company:

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Address:

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Telephone:

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Fax:

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Email:

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I'm interested in — please check all that apply

Serving on the Award Advisory Board

Judging the following entries: PSAs WWW sites

Entering the awards competition: Television PSA Radio PSA WWW site

Promoting the Aesculapius Awards competition

Sponsoring the Aesculapius Awards program

Being kept informed about the Aesculapius Awards program

Nominating colleagues who would welcome being informed about the awards program — please attach colleagues' contact information!

Participating in some other way — please specify below


Remarks/requests – if necessary, please attach additional sheets

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