Print, complete and mail or fax this form to:

INTERNATIONAL ASSOCIATION OF PHYSICIANS IN AIDS CARE
225 West Washington Street, Suite 2200, Chicago, Illinois 60606
Fax: 312 419-7160

IAPAC Norvir Advisory
Document: IAPAC Non-Member Print/Computer Reproduction Request
File: INA10lB

I am requesting written permission to:

( ) photocopy part or all of the IAPAC Norvir Advisory
( ) distribute via computer
( ) other (please specify) _____________________________________________

To whom will the requested copies be sent and/or distributed?--------------------------------

---------------------------------------------------------------------------------------

Request made by (Please type or print the following):

Name______________________________________________Degree________
(First) (Middle) (Last)

Title________________________________________________
(if applicable)

Organization_________________________________________
(if applicable)

Street Address:_________________________________________________

City________________________State/Province_________________________

Country_________________________ZIP/MailCode_____________________

Telephone__________________FAX_______________E-Mail_____________