Please fill out the form below. Note the lines with an  (*) asterisk must be filled in to submit the form. Thank you.

*   Yes, our organization endorses the BE SAFE Platform.

* My Name is:

* Group Name:

* Address:

* City:

* State:

* Zip code:

Phone/Fax:

E-mail/Web URL:

* Since the BE SAFE Platform will be delivered to the White House, CHEJ needs to independently verify all Platform endorsements.
How would you like us to verify your endorsement?

Mail E-mail

* Would you like to receive information and activity updates
on the BE SAFE campaign?

Yes        No

* Would your group build support for the BE SAFE Platform by
finding out how to hold a House Party?

Yes No Not Sure

* Would your group build support for the BE SAFE Platform by
holding or participating in an educational event?

Yes No Not Sure

* Are you a registered voter?

Yes No

Would your group make a donation to support the work of the BE SAFE Campaign?

Yes! I'll support now!   

Yes, Send us a Donation Card.

Please indicate your areas of interest (optional).
Children's Health
Clean Computers
Dioxin
Toxic Dumps
Environmental Justice
Green Schools
Factory Farms
Green Buildings
Green Energy
Hog Factory Farms
Incineration
Labor Issues
Landfills
Military Toxic Dumps
Mining
Nuclear Power Plants
Occupational Safety & Health
Persistent Toxic Chemicals
Pesticides
Right To Know
Sludge
Superfund
Water Pollution
Zero Waste

Are there other issues or comments you would like to share with us?