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On February 8, we're going to release a report on the results of our mercury study. But we don't want the human stories behind this report to get lost in statistics. That's why we want to hear your story.

Why did you decide to order a test kit? How does mercury pollution affect you? What do you feel our government should do about it?

Please take a moment to fill in the form below and your story may become part of the largest study of human mercury exposure in U.S. history. Thank you!

Personal information: 
* mandatory fields
* Title: * First Name: * Last Name:

* City/Town:State:

If not in the U.S., other State/Province: * Country

* E-mail: * Verify your E-mail:

Example: jane@mail.com
Example: jane@mail.com

* Home Phone: Cell Phone:
Example: 2025551212 Example: 3015551212


I give permission for Greenpeace to use my story as part of its campaign to end mercury pollution. I understand that it may be slightly edited for style.
Please limit your story to one page of text:

 If available, please include a photo of yourself:   






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