Seeking "Promises" From the Field banner
 

SUBMISSION FORM

Name (First Middle Last ): ________________________________________________

Title and Agency (if applicable): ________________________________________________

Mailing Address:

Street Address or Post Office Box: ________________________________________________

City State Zip Code: ________________________________________________

Social Security Number: ________________________________________________

Area Code/Telephone Number: ________________________________________________

E-mail Address: ________________________________________________

My Promise to Crime Victims: ________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

PLEASE CHECK YOUR AFFILIATION:

_____ Victim/Survivor
_____ Community-based victim services
_____ System-based victim services
_____ Law enforcement
_____ Prosecutor/U.S. Attorney
_____ Allied Professionals
_____ Judge/Court Personnel
_____ Probation/Parole

_____ Institutional Corrections
_____ Mental Health & Medical Providers
_____ Legislator/Elected Official
_____ Community Volunteer
_____ Inter-faith Community or Clergy
_____ Student
_____ Other: ____________________

Please return this Submission Form No Later Than Friday, March 21, to:
Office for Victims of Crime
Fax: 202-514-6383 or 202-305-2440

THANK YOU FOR PARTICIPATING IN THIS SPECIAL EVENT!

Previous Contents Next


Seeking Promises from the Field: Submission Entry Package (2003) March 2003
Archive iconThe information on this page is archived and provided for reference purposes only.