Submit your pledge

1. Organisation name *
2. First name *
3. Surname *
4. Position title *
5. Email (work) *
6. Phone (work) *
7. Organisation's website URL *

Organisation address

1. Street address *
2. Suburb/town *
3. State *

   -- Please Select --ACTNSWNTQLDSATASVICWA
4. Postcode *

Taking the pledge is a demonstration of your organisation’s commitment to prevent DFV.

As part of your commitment, please provide your organisation logo and a brief description of the action/s you are committing to taking.

1. Organisation logo. * Please upload a full-colour version of your logo with a transparent background in JPG or PNG format sized 100 x 100 pixels. Logos provided that do not meet these specifications cannot be published and will need to be re-supplied.
2. Description of the action/s you are committing to taking. * Please limit to 250 words.

• I am providing the information in this form to the department for the purpose of publication, including publication online.
• I understand that publication of the information I have provided in this form on the internet may mean that it is transferred overseas, and I consent to that transfer.
• I have obtained consent to the publication and overseas transfer of the personal information of all persons whose images and personal information are contained in my submission.

1. Consent: *

   • Yes, I provide my consent.

I am authorised to take the pledge to end domestic and family violence on behalf of my organisation.

1. Pledge: *

   • Yes, I am authorised to take the pledge.