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Sign the Petition Form

By filling out and submitting this form, you are signing your support of the Universal Declaration on Circumcision, Excision and Incision and The Ashley Montagu Resolution. Only fields you have selected as being "Public" will appear to the public on the website. Fields marked "Private" will only be shown to officials during the process of officially submitting the petition sigatures.

If you mark both your first name and last name as "Private," your signature will not appear to the public on our website, but will be maintained on the official list of signatures.

If you mark any field private, at no time will we give or sell the information in that field, be it your email address or other information, to any other person or organization for purposes other than promoting genital integrity. If you make any field public, it will be available to anyone who visits your signature on the site.

When you submit the form, we will read your signature for acceptance and email an acknowledgement and confirmation of it to the email address you have listed.

Required fields are in red and marked with a *.

Salutation (Mr., Ms. Mrs., etc.):  Public
 Private
First Name*:  Public
 Private
Middle Name or Initial:  Public
 Private
Last Name*:  Public
 Private
Suffix (Jr., III, etc.):  Public
 Private
Professional Designator(s) (Ph.D., LL.D., MD, etc.):  Public
 Private
Email Address*:  Public
 Private
Confirm Email Address*:  
May we contact you about genital integrity issues?  Private Always
Not more than once a week
Not more than once a month
Not more than once a quarter
Not more than semi-annually
Not more than once a year
Never
Address:  Public
 Private
Address (Second Line):  Public
 Private
City:  Public
 Private
State / Province:  Public
 Private


If you do not live in the United States, Canada, or Australia, please enter your state or province:

(We would appreciate it if we can publish your state or province publicly,
but if that is not possible, click “Private” and your request will be honored.)

Postal / Zip Code:  Public
 Private
Country*:  Public
 Private

(We would appreciate it if we can publish your country publicly, but if that is not possible, click “Private” and your request will be honored.)

Phone Number:  Public
 Private
Website URL(s):  Public
 Private
   Public
 Private
Birth Date:  Public
 Private
Sex:  Public
 Private
Male Female
Education:  Public
 Private
Completed Grade School
Completed High School
Some College
Completed 2-Year College
Completed 4-Year College
Completed Post-Graduate College
Occupation:  Public
 Private

Specific Occupation or Affiliation:
Award / Prize / Recognition:  Public
 Private
If you have received any major awards or recognitions, select the award or recognition from the pulldown list below. If it is not listed, enter it in the space marked "Unlisted Award Name." Then, enter any specific details about that award or recognition, such as the specialty it was in, and the year it was received.

Award Name: OR
Unlisted Award Name:
Award Detail (Physiology, Medicine, etc.):
Year Received: (ex. 1988)
Religion:  Public
 Private

Specific:
Your Comments on Genital Integrity Subjects:  Public
 Private

By filling out and submitting this form, you are signing your support of the Universal Declaration on Circumcision, Excision and Incision and The Ashley Montagu Resolution. Only fields you have selected as being "Public" will appear to the public on the website. Fields marked "Private" will only be shown to officials during the process of officially submitting the petition sigatures.

If you mark both your first name and last name as "Private," your signature will not appear to the public on our website, but will be maintained on the official list of signatures.

If you mark any field private, at no time will we give or sell the information in that field, be it your email address or other information, to any other person or organization for purposes other than promoting genital integrity. If you make any field public, it will be available to anyone who visits your signature on the site.

When you submit the form, we will email an acknowledgement to the email address you have listed. In order for your public or private signature to be approved, you must reply to that email acknowledgement. Please reply.



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