ACTWDIP IPMLADDBLlPIBniA Salk Vaccine Signup Sheet

Note: send this fonn completed to the following address and ACT-UP PHILADELPHIA will present it for you to the trial sponsors: ACT-UP Philadelphia, 201 South Camac Street, Science & Medicine Committee, 201 South Camac Street, Philadelphia, PA 19107

John L. Turner, MD The Graduate Hospital Pepper Pavilion 19th & Lombard Street Philadelphia, PA 19146 or Fax: (215) 893-7363

Dr. Bert Slade Immune Response Corporation and Rorer- Rhone Poulenc Corp.

Date: (Note: the date you sign is important!) Dear Drs. Turner & Slade: I have noted with great interest the progress you have made with the Salk/Immunogen HIV Vaccine in slowing the progression of HIV infection, and, in some cases,reversingthe decline of CD4 cells. As an HIV-infected person, I am interested in the possibility of participating in an open label, massive trial, to prove the efficacy of this treatment modality, as well as the dose. Please contact me with information as to the trial status, my priority in being evaluated, the protocol, and needed medical information from me for my possible evaluation, and possible participation. I understand that this information will be kept confidential at all times. Thank you. Name: Address: City, State, Zip:_ My doctor is: Home Telephone:

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