Light Up The Landmarks
Thank you for your dedication to bringing awareness! Please complete the form below for each landmark you have contacted. We look forward to seeing buildings and landmarks across the country lit up blue for Pain Awareness Month!
Last Name *
Your answer
First Name *
Your answer
Preferred Email *
Your answer
Your City *
Your answer
Your State *
Your answer
Name of the Business/Landmark *
Your answer
City where the Business/Landmark is located *
Your answer
State where the Business/Landmark is located *
Your answer
How did you first contact the business/landmark? *
Required
Date of initial contact *
Your answer
First & Last Name of Primary Point of Contact *
Your answer
Point of Contact's Phone and/or email address *
Your answer
Status of Request *
Date of Approval or Denial *
MM
/
DD
/
YYYY
If denied, what was the reason for the denial? (Complete only if denied)
Your answer
If approved, what are the date(s) they will be lighting up blue? (Complete only if approved)
Your answer
Does the business want to provide a photo or two of the landmark lit up blue and/or decorated with their Beautify in Blue decor? (we need to know if we need to find someone to take the photos) *
Required
Will there be any PAM events taking place at the landmark? If so, please provide details including the date(s). *
Your answer
Photograph Contact - Please provide the name and contact information for the person who will be taking the photographs of the landmark lit up blue. *
Your answer
Additional Details - Please provide any details that you feel should be shared regarding the business/landmark
Your answer
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