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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: