Agency Membership

Please print this form, provide us with the following information, and submit your membership form and a check in the amount of $75 to NCVAN. Additional members in the same agency may subscribe for an additional $10 per person. We thank you for your support and look forward to you working within our network!

Agency Name:

Agency Mailing Address :

Phone Number:

* Email Address: :

Membership Category:

Victim/Witness Assistant

Law Enforcement

Department of Justice

Service Provider

District Attorney

Advocate

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