Leading By Example Sign-On Form

Leading By Example Organization/Company Pledge

Partners in the Leading By Example initiative agree to support and amplify the goals of encouraging annual flu vaccination for all individuals age 6 months and older.
Name of Organization/Company (as it should be listed)*
Website*
Twitter Handle
Name of Authorized Representative*

First NameLast Name
Title of Authorized Representative*
E-mail Address of Authorized Representative*
Phone Number

Area CodePhone Number
Country*
Should be Empty:

Leading By Example Organization/Company Pledge