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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.
*
1
. Please sign by giving us your name:
Please sign by giving us your name:
First Name:
Last Name:
2
. Please give use your title and affiliation.
Please give use your title and affiliation.
Your Title:
Your Organization:
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:
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Please do not publish my affiliation and title.
4
. Contact Information (optional)
Contact Information (optional)
Street Line 1
Street Line 2
City
State
Zip
Daytime Phone
Assistant Name
Assistant Phone
5
. Email Address (optional, but if you give us one, we can thank you!)
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.
6
. Agreements, (optional, please check all that apply)
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.
7
. (optional)
I would like to make a donation to Jane Doe Inc. in the amount of:
(optional)
I would like to make a donation to Jane Doe Inc. in the amount of:
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