WRD Ambassador Registration 2010 Survey

WRD Ambassador Registration 2010

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Welcome! This is the registration page for joining as an Ambassador for the
Jane Doe Inc. Massachusetts White Ribbon Day
March 2, 2010!

Ambassadors are men who have taken the White Ribbon Day Pledge and join the campaign to serve as an example to others. Ambassadors agree to wear the White Ribbon on March 2, 2010; recruit 5 or more friends and colleagues to wear the ribbon on that day; and give your permission for your name to be published on print and web materials.

Please register 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. The Duration of My Ambassador Registration is for:

The Duration of My Ambassador Registration is for: 3 Years (preferred)

2 Years

1 Year

3. Please give use your title and affiliation.

Please give use your title and affiliation. Your Title:
Your Organization:

4. I give permission for Jane Doe Inc. to publish my name, affiliation and title in the list of Ambassadors 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 Ambassadors 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Please do not publish my affiliation and title.

5. Contact Information

Contact Information Street Line 1
Street Line 2
City
State
Zip
Daytime Phone
Assistant Name
Assistant Phone

6. Email Address

Email Address

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.