FORM FOR SIGNATORIES/ENDORSERS OF THE WOMEN'S DECLARATION ON POPULATION POLICIES

In Preparation for the 1994 International Conference on Population and Development

Women and women's organizations are invited to be signatories. Men and all other organizations are invited to endorse the Declaration.

Please circle one: Signatory / Endorser

Please type or print:

Name _________________________________________

Title __________________________________________

Organization ___________________________________

Address _______________________________________

City ___________________________ State __________

Country _______________ Zip/Postal Code __________

Telephone _____________________________________

Fax ___________________________________________


Please circle the appropriate line:

My organization endorses the Declaration.

I list my organization for identification/affiliation purposes only.

(My signature does not imply organizational endorsement.)

Is your organization a membership organization: Yes / No

If yes, how many members do you have? ______________

Would you like to be a member of the Women's Voices '94 Alliance which has been established to promote the Declaration? -- Yes / No

Please write one or two sentences about your organization, and the constituency it serves, below: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Return form to, or for further information, or for a list of signators and endorsers, contact the:

International Women's Health Coalition
24 East 21st Street
New York, New York 10010, United States
tel: 212-979-8500, fax: 212-979-9009