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_______________