Insurrection Participation Declaration Form
Declare your participation details clearly and accurately using this form.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name or Alias
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Participation Details
Role or Relationship to the Event
*
Location / Jurisdiction of Participation
*
Date(s) of Involvement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Narrative Description of Involvement
*
Declaration and Submission
Acknowledgment
*
I confirm I am submitting a declaration about my involvement and understand the information should be accurate.
Signature
*
Submission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Declaration
Submit Declaration
Should be Empty: