Coalition to Protect
Georgia’s Bill of Rights

Sign-On  Form

Organization Name: ______________________________________________________________

Contact Name: ______________________________________________________________

Mailing Address: ______________________________________________________________

Email Address: ______________________________________________________________

Phone:       _____________________  Fax: ____________________________

_____List my ORGANIZATION as a member of the Coalition to Protect Georgia ’s Bill of Rights. (Print name above exactly as you would like it listed)

_____Do NOT list my organization as a member of the coalition, but do keep us on your distribution list for future updates

_____ List me as in INDIVIDUAL supporter. My organization will be listed for     information purposes only

_____Take my name off your distribution list 

Please return form to Shelley Rose at the address/fax below or Email: srose@adl.org

Anti-Defamation League, Southeast Region
3490 Piedmont Road, Suite 610 
Atlanta, GA  30305

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