WRD Pledge Registration 2010

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Welcome!

The Massachusetts White Ribbon Day Pledge
for Men and Boys

Please take the pledge by completing the following form.

The Massachusetts White Ribbon Day Pledge 2010:
From this day forward, I promise to be part of the solution
in ending violence against women.

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* 1. Please sign by giving us your name:

First Name:

Last Name:

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* 2. Please give use your title and affiliation.

Your Title:

Your Organization:

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* 3. I give permission for Jane Doe Inc. to publish my name, affiliation and title in the list of pledge signers on the Web and in publications.

Except as follows:

Please indicate that my company/organization affiliation is for identification purposes only.

Please do not publish my affiliation and title.

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* 4. Contact Information (optional)

Street Line 1

Street Line 2

City

State

Zip

Daytime Phone

Assistant Name

Assistant Phone

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* 5. Email Address (optional, but if you give us one, we can thank you!)

Privacy Notice:
Your contact information will be used for internal purposes only and will not be shared with sources outside of Jane Doe Inc. without your expressed permission.

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* 6. Agreements, (optional, please check all that apply)

I promise to wear the white ribbon on White Ribbon Day in Massachusetts.

I promise to recruit 5 friends and colleagues to wear the white ribbon with me.

I have a few ideas about reaching more men, contact me.

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* 1. Please sign by giving us your name:

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* 2. Please give use your title and affiliation.

Question Title

* 3. I give permission for Jane Doe Inc. to publish my name, affiliation and title in the list of pledge signers on the Web and in publications. Except as follows:

Question Title

* 4. Contact Information (optional)

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* 5. Email Address (optional, but if you give us one, we can thank you!)

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* 6. Agreements, (optional, please check all that apply)

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* 7. (optional) I would like to make a donation to Jane Doe Inc. in the amount of:

* 3. I give permission for Jane Doe Inc. to publish my name, affiliation and title in the list of pledge signers on the Web and in publications.

Except as follows:

* 7. (optional)
I would like to make a donation to Jane Doe Inc. in the amount of: