Tribal Traffic Safety Data Center Training and Technical Assistance Request Form

The National Indian Justice Center will be providing training and technical assistance (T/TA) for the Tribal Traffic Safety Data Center project. To initiate a request for technical assistance, please complete this form online, send an e-mail, fax, or call.

Send requests via e-mail to benmyers@nijc.org or call Ben Myers, Staff Attorney, at (707) 579-5507. You can fax the printed form or written request to fax# (707) 579-9019.

Question Title

1. Date Submitted: (Required.)

Date that this T/TA Request Form was completed and submitted:

Date

Question Title

2. Please provide the following contact information: (Required.)

Name:

Tribe or Organization:

Title:

Address:

City:

State:

Zip:

Email Address:

Phone Number:

Question Title

3. If you have a resource request and/or require an item to be faxed, please provide your fax number:

Fax Number:

Question Title

4. Please provide a deadline date if your request is time sensitive:

Info required by:

Date

Question Title

* 1. Date Submitted: (Required.)

Question Title

* 2. Please provide the following contact information: (Required.)

Question Title

* 3. If you have a resource request and/or require an item to be faxed, please provide your fax number:

Question Title

* 4. Please provide a deadline date if your request is time sensitive:

1. Date Submitted: (Required.)

2. Please provide the following contact information: (Required.)

3. If you have a resource request and/or require an item to be faxed, please provide your fax number:

4. Please provide a deadline date if your request is time sensitive: