I agree with the Leipzig Declaration and wish to add my name to the list of signers.



________________________     Y/N                               ________________________
Print name                                                     Signature

_____________________________________________________
Address

________________________     Y/N                               ________________________
Professional affiliation/employer                              Highest degree & field
(present or former)

________________________                                       ________________________
Telephone/Fax number(s)                                        Email address



Professional qualifications related to climate (e.g., AMS or AGU membership, relevant publication or position)



Please circle either Y or N to indicate if we may use your name and/or affiliation.

Please print out this agreement and fax to 815-461-7448 or mail to:
Science & Environmental Policy Project
1600 South Eads Street, Suite #712-S
Arlington, VA 22202-2907
Tel/Fax 703-920-2744

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