2. I believe that Everyone Belongs in Pleasant Hill. 

4. I pledge to (check all of the boxes below):*

   1. Maintain a welcoming, inclusive and safe environment for all community members, neighbors, guests, employees, visitors, customers, vendors, and clients.
   2. Actively work towards cultivating a sense of belonging in our community.
   3. Display the Everyone Belongs decal at my business or residence.
6. First name to be included on certificate if only taking the pledge as an individual (not a business)
7. Last name to be included on certificate if only taking the pledge as an individual (not a business)
9. Business name to be included on the certificate if taking the pledge as a business. (Please include an individual name followed by a comma and the business name if you want both a person and business name included (eg John Smith, Smith's Family Business)
13. I would like my certificate and decal sent to me in the following format (select one):*

    1. Printed certificate/decal mailed to me (fill out mailing fields below)
    2. Emailed certificate/decal (skip the mailing address section and fill out email address field in the section after)
    3. Both paper and emailed certificate/decal me (fill out mailing address and email fields below)

15. Fill out this section only if requesting a mailed certificate/decal:

17. Please provide your mailing address (number and street) only for a mailed certificate/decal.
18. Please provide your mailing address apartment, condo or suite number and letter only for a mailed certificate/decal.
20. Please provide your mailing address city for the mailed certificate/decal.
21. Please provide your mailing address state for the mailed certificate/decal.
22. Please provide your mailing address zip code for the mailed certificate/decal.
26. Please provide your email address for the emailed certificate/decal as well as for staff or the Diversity Commission to contact you with any questions about your form.
30. I would like my name and/or business name to be added to the public website to show that I have taken the pledge (check yes or no below).*

    1. Yes
    2. No
31. By typing my name and/or business name in the box below, I am confirming my, and/or my business's, commitment to the Everyone Belongs Pledge.*
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field