Date: Mon, 30 Sep 1996 09:30:35 -0500

From: Susan Mellott

To: pr.bruxelles@agora.stm.it

Subject: Fast

APPLICATION FORM FOR THE FASTING DIALOGUE

(X) I will participate in the fasting dialogue for the liberation of Gedhun Choekyi Nyima, XIth Panchen Lama, and of the Chinese dissident Wei Jingsheng.

* I have the intention to fast (X) 1 Day

* We would like to know the dates of your fasting:

(X) October 2nd

Name: Susan Mellott

Complete address: 922 Kinsmoor Ave. - Fort Wayne, IN, 46807

Country: United States

Telephone 219-744-5676

e-mail: smellott@everest.acpl.lib.in.us

Profession/function: Computer Programmer

Organization: none