Victim Service Provider Training and Technical Assistance Request Form

Agency *

Name *

JobTitle

Address *

City *

State *

Zip *

Phone *

Fax

Email *

Training or Technical Assistance?

Describe the Training Need or Technical Assistance Need *

What is the preferred timeframe for the training or technical assistance to take place? *


Is your agency/position funded by a grant through DJCS? (If yes, please provide the grant and project number below) *


DJCS Grant (If No, Mark as N/A) *

DJCS Project Number (If No, Mark as N/A) *

Attachments