Individual Endorsement of the Louisville Charter
This form is for INDIVIDUALS that want to add their own name as a public endorser of The Louisville Charter for Safer Chemicals. Many individuals are adding their names in support, including:
- Elected officials;
- Medical and public health professionals;
- Scientists and technical experts;
- Business leaders;
- And many others.

If you want to add your organization as an Organizational endorser of the Louisville Charter, please use this form instead: https://forms.gle/Ej8hhhj2jFw2reYH6 Businesses can also endorse the Charter here: ADD NEW FORM LINK

All individual endorsements may be publicly listed on Coming Clean's web site, or used publicly in other ways. Please fill in the information on the form EXACTLY as you want it to appear on public pages and documents.

Affiliations (such as colleges or universities) will be listed as you provide them in this form, noting that they are for identification purposes only, and that the institution or other entity listed is not necessarily an endorser of the Charter. If you do not want your affiliation listed publicly, please do NOT include it in response to that question.
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The information in the first three questions below (your name and credentials, your affiliation, and areas of expertise) may be listed publicly.
Your Name (please include degrees or credentials if desired, listing everything exactly as you want it to appear publicly) *
Affiliation (may be included in public lists, will be noted as for identification purposes only in any public listing,  please enter exactly as it should appear). If you do NOT want your affiliation listed publicly (even for identification purposes) do NOT enter it here.
How would you describe your work or expertise? (Individual endorsers may be grouped into these categories in public lists.)
The remaining questions (below this point) are for internal use only. These responses will NOT be shared publicly.
Your Email Address *
Your Phone Number
Your Location (city, state)
Please check boxes below if you would like to:
Is there anything else you'd like us to know? (For example, if you don't want your institution or employer listed publicly as an affiliation even for identification purposes, and you did not enter an Affiliation above, you can provide your affiliation here and it will NOT be listed publicly.)
Confirmation of Individual Endorsement of the Louisville Charter *
Required
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