SECTION
A:
REGISTRATION
Facility:
_____________________________________________________________________________________________

Primary
Contact
Name:
_______________________________________________________________________________

Title:
_______________________________________________________________________________________________

Address:____________________________________________________________________________________________

City:
_____________________________________
State:
______________________________
Zip:
__________________

Phone:
_____________________________________
Fax:
____________________________________________________

E­
mail:
________________________________
Web
Site:
____________________________________________________

Describe
your
facility
and
any
relevant
affiliations:________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

If
your
facility
has
engaged
in
other
waste
reduction
efforts,
you
might
be
eligible
to
receive
H2E's
"
pioneer"
designation.


My
facility
pledged
to
reduce
mercury/
waste
under
other
efforts
(
e.
g.,
state
pledge
programs).

Please
describe._____________________________________________________________________________________


My
facility
has
completed
a
facilitywide
waste
assessment.

Please
describe._____________________________________________________________________________________

Do
you
prefer
receiving
information
from
H2E
in

hardcopy
or

electronically?

SECTION
B:
H2E
PLEDGE
By
becoming
a
partner
of
the
H2E
program,
you
will
be
asked
to
take
the
following
pledge:

Partners
of
the
H2E
program
pledge
to
support
its
goals
to
eliminate
mercury
waste
by
2005
and
reduce
total
waste
by
33
percent
by
2005
and
by
50
percent
by
2010,
and
to
minimize
persistent,
bioaccumulative,
and
toxic
pollutants.
Further,
we
pledge
to
voluntarily
assess
our
waste
management
and
environmental
programs,
collect
H2E
baseline
data
for
tracking
national
progress,
and
establish
goals
to
achieve
significant
waste
reduction.

To
assist
your
facility
in
meeting
these
pledge
commitments,
the
H2E
program
will
provide
you
with
tools
and
information.


My
facility
is
ready
to
pledge
to
the
H2E
program.

Signature
of
Senior
Administrator
______________________________________________________________________

Print
Name__________________________________________________________________________________________

Title
__________________________________________________________________
Date_________________________

Please
fold
and
mail
or
fax
to
202­
234­
9121
or
register
electronically
at
<
www.
h2e­
online.
org>.
Call
us
at
800­
727­
4179
for
more
information.

Before
the
H2E
program
can
request
additional
information,
it
must
receive
approval
by
the
Office
of
Management
and
Budget.
Under
the
Paperwork
Reduction
Act,
the
government
seeks
to
protect
businesses
like
yours
from
burdensome
paperwork.
To
that
end,
we
would
like
any
comments
from
you
on
this
pledge
statement
and
its
implications.
&
Partner
Registration
Pledge
Form
Working
Together
to
Achieve
Healthy
Communities!
Working
Together
to
Achieve
Healthy
Communities!

Hospitals
for
a
Healthy
Environment
1755
S
Street,

Suite
6B
Washington,

DC
20009
