* 1. Full Name 

* 2. Title 

* 3. Organization/Agency

* 4. Street Address

* 5. City

* 6. State

* 7. Zip Code

* 8. Phone

* 9. E-mail

* 10. Best way of communicating with you?

* 11. Are you generally available to meet telephonically once a month?

* 12. Would you be interested and able to attend and serve as faculty for full day trainings during business hours up to 3 times a year?

* 13. Are you available to attend a mandatory training for trainee faculty selected to be held in Georgia on August 6-8, 2018?

* 14. Please provide your total years of experience working with victims of domestic violence, sexual assault, dating violence, and/or stalking?

* 15. Please provide your total years of experience working with immigrant victims of domestic violence and/or sexual assault?

* 16. In the box below, please discuss your experience as a trainer including providing instruction for law enforcement officers and/or prosecutors.

* 17. In the box below, please discuss in person or on line trainings you have attended in the past two years on topics including domestic violence, sexual assault, stalking, dating violence and immigrant or limited English proficient victims of these crimes.

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