Form:

Global Outreach Endorsement Form

Date: 
Organization's name: 


Country and headquarters address: 


Contact Person: 
Email address: 
Website: (if any) 

Geographic Area of Organization's Work 
[ ] Locality, State, Province or Region of Country 
[ ] National 
[ ] Regional (two or more countries) 
[ ] International 
Name of Geographic Area : 

Type of Organization (check one) 
[ ] Environmental Organization 
[ ] Health Advocacy Organization 
[ ] Development Organization 
[ ] Professional Organization 
[ ] Peoples Organization 
[ ] Trade Union 
[ ] Consumer's Organization 
[ ] Other 

Possible Chemical Safety Issue Areas of Interest (check as many as apply) 
[ ] Promoting improved national legislation, regulations and/or enforcement aimed at achieving the SAICM 2020 objective; 
[ ] Protecting farmers, peasants, workers and/or communities from harms caused by exposure to harmful agricultural chemicals; 
[ ] Protecting children, the general public and the environment from harms caused by exposure to toxic metals such as lead, mercury and cadmium; 
[ ] Protecting human health and/or ecosystems from harms caused by exposure to persistent organic pollutants and other toxic chemicals of concern; 
[ ] Protecting workers from occupational exposures to toxic chemicals; 
[ ] Monitoring the presence of synthetic toxic chemicals in toys or other consumer products; in humans; and/or in the environment; 
[ ] Promoting waste minimization and sound waste management aimed at protecting the public from harms caused by polluting facilities and practices such as open burning, waste dumping, inappropriate landfills, and polluting incinerators.