MoVA Membership Form

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.

Please print, complete and mail this form, along with dues to:

MoVA
PO Box 2232
Jefferson City, MO 65102
Attn: Membership Committee

Make checks payable to MoVA. Memberships will not be processed until full payment is received by the MoVA Office. If you have questions about the application process, please call the MoVA Office at 1-800-698-9199.

Or submit on-line at http://mova.missouri.org/new_member_app.htm

Member Information:

Name/Organization/Contact: ______________________________

Mailing Address: ________________________________________

Work Phone: ___________________________________________

Fax: __________________________________________________

E-Mail: ________________________________________________

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