MoVA Membership Form

Thank you for your membership and continued support of the crime victims in Missouri and to the Missouri Victim Assistance Network, Inc. Your membership will expire on December 31, 2008. Click here for a printable form.

MoVA Membership Application Form

Name/Organization/Contact:

Mailing Address:

City: State: Zip:

Work Telephone: Fax:

E-mail:

Membership Type	Representative Name(s)
Individual $40 (1 representative)
Agency $75 (2 representatives)
Organizational $150 (5 representatives)
Sponsor $500 (5 representatives)

Fees due: $ Check No.:

Applications will not be processed until full payment is received by the MoVA Office. Your submission will not be received if a check number is not included in the on-line renewal form. If you have questions about the on-line application process, please call the MoVA Office at 1-800-698-9199. Please make checks payable to MoVA and remit to:

Missouri Victim Assistance Network (MoVA)
P.O. Box 2232
Jefferson City, MO 65102
ATTN: Membership Committee

Click here for a printable form.