APPLICATION FOR INDIVIDUALS
TO BE LISTED IN THE
US
PEACE REGISTRY
The US Peace Registry recognizes and documents the activities of US 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.
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Email address (will not be published without your permission):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Telephone (optional, will not be published):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 anti-war/peace
behaviors in chronological order from
oldest to most recent. Use only
one sentence or sentence fragment for each anti-war 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). You
can review some sample listings at www.uspeacememorial.org/Registry. We do not
want this to become an onerous task.
Just include whatever information is readily available to you. Additional entries can be included at a
later date. The US Peace
Registry will always be a work in
progress.
Provide at least one form of documentation (evidence) clearly linking you to a specific
anti-war/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 peace/anti war website reference
to you, letter to the editor showing the name of the publication and date; a
letter from a congressional representative acknowledging your anti-war
position, or a newspaper article mentioning you and your activity.
I have made the following tax
deductible contribution to the Foundation:
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 organizationŐs
website: www.USPeaceMemorial.org/Donors 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 and a signed copy of this form to:
US Peace Memorial Foundation, Inc.
P.O. Box 16118
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 - 2008, US Peace Memorial Foundation, Inc.