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Victim Witness Notification Program Enrollment Request Form

To enroll in the Victim/Witness Notification Program, complete and submit the registration form below. When you submit this information it will be a secured transmission and remain confidential. The person who victimized you will not know you are being notified and will not have access to your address or telephone number.

As you enter the information, press 'Tab' to move from field to field.

Information about your age and sex is voluntary and will be used for statistical purposes only.

DSHS wants to be able to quickly and reliably contact you prior to the release of the perpetrator from DSHS custody. Please choose the most effective method of notifying you below. In the event of an escape we will contact you by the most expedient means reasonably possible. It is your responsibility to keep us updated on your current address, email and phone numbers.

* Indicates Response Required


ENROLLEE INFORMATION

*Type of Notification Delivery:

*Your Name:

Date of Birth: (mm/dd/yyyy)

Sex:
Female
Male

*Street or Mailing Address:

*City:

*State:

*Zip Code:

Home Telephone: 123-123-4567

Work Telephone: 123-123-4567

Message Telephone: 123-123-4567

*E-Mail: (required if you selected to be notified by e-mail)

*Your Role in this Case: Check One
Victim
Witness
Next of Kin to Victim
Guardian of Minor Victim
Other (A-Z, a-z)

OFFENDER INFORMATION

*Name of Person Who Committed the Offense (Last, First, Middle):

Sentence Date (if known): (mm/dd/yyyy)

Case Number (if known):

County of Conviction:

Offense:

*Select the type of offender: