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The Massachusetts White Ribbon Day Pledge
for Men and Boys

Please take the pledge by completing the following form.

(Campaign Website: www.janedoe.org/whiteribbonday)

The Massachusetts White Ribbon Day Pledge:
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:

2. Please give use your title and affiliation.

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:

4. Contact Information (optional)

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.

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

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