Instructions

If you prefer NOT to fill out this form online, please download the form here and print it. Next, contact us by email at contact@wearetheevidence.org to coordinate how to send it back to us.

Part 1: Personal Information


Upload photo of yourself?



Types of Injury

  • Electromagnetic sensitivityTumors and cancerOther

Part 2: Testimonial

To which wireless device(s) do you attribute your condition?

Cell phoneCell tower/antennaWireless 'smart' meterWi-FiOther

What symptoms do you experience when you are exposed to radiation? (50 words max.)

How did becoming injured by wireless affect your life? (Your family, living situation, education, job, finances?) (200 words max.)

How has becoming injured by wireless affected your ability to function in society? (200 words max.)

How did you make the connection between the symptoms you experience and wireless radiation? (200 words max.)

Do you have a wireless utility meter? YesNo

If yes, how did it affect your life? (150 words max.)



words. Please limit to 150 words or less.

What else would you like to tell the public and public officials? (100 words max.)



words. Please limit to 100 words or less.

Additional Comments (100 words max.)



words. Please limit to 100 words or less.

If you know about a doctor or healthcare professional who acknowledges electromagnetic sensitivity, we would appreciate it if you provide us with his/her name and contact information. (50 words max.)



words. Please limit to 50 words or less.

Are you currently involved with public awareness work on the issue of wireless technology harms? Please elaborate. If you are not involved, would you like to be? (100 words max.)



words. Please limit to 100 words or less.

If an article about you have been published - please share the link here

If you have a website - please put the link here

Part 3: Contact Information


Contact information will be used only by WATE and will not be shared with any other organizations or persons.

Part 4: Authorization


I authorize "We Are The Evidence" to use the information provided in my testimonial as follows:

I authorize WATE to use my picture (if provided), my personal information in Part 1 and my testimonial in Part 2 for its actions, including on its website.I authorize WATE to use my personal information in Part 1 and my testimonial in Part 2 but NOT my picture (if provided).I authorize WATE to use only my testimonial in Part 2 but NOT to use my picture (if provided) NOR to disclose my name NOR the name of my town, but allow WATE to use the rest of the information in Part 1.