APPLICATION
FOR INDIVIDUALS
TO BE LISTED
IN THE
US PEACE REGISTRY
The US Peace Registry
recognizes and documents the activities of U.S. citizens and organizations that
have opposed and/or resisted American military solutions, rather than
diplomacy, to solve international problems. It is hoped that these role models for
peace will inspire more Americans to speak out against war. The specific behaviors listed under each
record are intended to provide ideas and guidance for future generations.
Please copy the following form into an email or Word document and
send the completed form to Registry@USPeaceMemorial.org. If you also represent an antiwar
organization, please complete the application at www.uspeacememorial.org/Organization.htm
Please provide the following information about yourself:
Name:
Complete Mailing Address (only city and state will be
published):
Do
we have your permission to publish
your city name?
Email address (will not be published without
your permission):
Do
we have your permission to publish
your Email address?
Telephone (optional, will not be
published):
Describe yourself in 30 words or less.
Examples:
James Doe is a bricklayer working on housing construction in Naples, FL and a
former Navy SEAL. Joan Doe, Ph.D.
is a retired University of Michigan biology professor living in Detroit,
MI. Jill Doe is a graduate student
in International Studies at Stanford University. Jeff Doe stays at home with his two
young sons in Austin, TX and volunteers for Habitat for Humanity.
List your primary antiwar/peace
behaviors and activities in chronological order from oldest to most recent. Use only one sentence or sentence
fragment for each antiwar activity.
Give the date(s) at the end of each activity. Do not include your name again. Use
behaviorally specific language (e.g., Wrote anti Iraq war Letter to the
Editor, published in the Toledo Blade,
3/7/04). Review listings examples at
www.uspeacememorial.org/registry.htm.
We do
not want this to become an onerous task.
Just include whatever information is readily available to you. Additional behaviors can be included at a later date. The US Peace Registry will always
be a work in progress and a listing does not need to be comprehensive.
Unless you have been asked by a
representative of the Foundation to complete this application, please provide
at least one form of documentation
(evidence) clearly linking you to a specific antiwar/peace activity for every
five entries you list. At least one
piece of evidence must be included with short entries. Examples of documentation may include a
publication reference, peace/antiwar website reference to you, letter to the
editor showing the name of the publication and date; a letter from a
congressional representative acknowledging your antiwar position, a newspaper
article mentioning you and your activity, etc.
I have made the following tax deductible contribution to the
Foundation (DONATION NOT REQUIRED): ___________
For a
limited time, anyone who donates at the $100.00 or more level will become a
Founding Member of the Foundation and will be recognized on the organizationÕs
website: www.uspeacememorial.org/Donors.htm
and in a separate donor section of the US Peace Registry (name and state
only). Although membership in the
foundation or making a donation at any
level is not a prerequisite to being listed in the US Peace Registry, we ask
that you consider supporting the US Peace Memorial Foundation, Inc. and telling
your friends and associates about our website: www.USPeaceMemorial.org. Without your
tax deductible contributions, the US Peace Memorial may never be built. Contribute
Now!
I certify that the above
information is accurate and that US Peace Memorial Foundation, Inc. has my permission to
publish the above information in the US Peace Registry. I understand that the Foundation will
not sell or rent my name and personal information to any other organization.
It is understood and agreed that the editors reserve the
right to select material consistent with the US Peace Registry style
and space limitations. In the event
of errors, the sole responsibility of the US Peace Memorial Foundation, Inc.
will be to correct such errors in a succeeding edition of the publication. Such correction of errors is in lieu of
any other legal remedy and the Foundation expressly disclaims all other
liability for loss or incidental or consequential damage whether arising from
negligence or any other causes.
Submission of this form by the named individual constitutes permission
to publish the information in print, electronic, or other formats.
Signature:
_____________________________________________ Date:
______________
Please email your
completed application to: Registry@USPeaceMemorial.org.
Also, please mail
your documentation, a signed copy of this form, and any donation to:
US Peace Memorial Foundation ¥ 334
East Lake Road #405 ¥ Palm Harbor,
FL 34685
US Peace Memorial Foundation, Inc. is a tax-exempt 501(c)(3)
public charity.
The IRS has determined that donations are tax deductible.
Copyright 2005 - 2011, US Peace Memorial Foundation, Inc.