Today's Date *

MM

DD

YYYY

Organization Representative *

First Name

Last Name

Representative's Phone Number *

(###)

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Physical Address *

This must be a business address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Organization's Phone Number *

(If different from representative's phone number)

(###)

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Are the staff members in your organization certified Victim Service Providers (VSP) through the SC Attorney General's Office, Division of Crime Victim Services Training, Provider Certification and Statistical Analysis? *

Yes, all of our staff members are certified

No, VSP certification does not apply to our organization

Some of our staff members are certified

Acknowledgment: Please be aware that the SC Victim Assistance Network reserves the right to include organizations on our website. Additionally, we collaborate with the Attorney General's Office to confirm agency and VSP status. *

Yes, I acknowledge that I have read above statement.