Request for Computer-based Training Course
Domestic Violence and the role of Community Corrections

Instructions: Qualified registrants may receive one copy of the computer disc containing this course. Discs will be furnished free while supplies last. Please allow two weeks for processing your request and receiving your disc. All information requested below must be completed to receive a disc. Be sure that information provided for this request form matches the information you provide when applying for a certificate of completion.


*required fields

Identifying Information
Enter your name as you will want it to appear on your certificate of completion:

*First Name  
*Last Name  
*Title  
*Company/Agency  
*Address  
Address (cont.)  
*City  
*State/Province  
*Zip/Postal Code  
*Country  
*Work Phone  
FAX  
*E-mail  
*Re-enter E-mail  
  (We must receive your e-mail address accurately to contact you.)
 
Agency and Professional Information
Type of Agency in which You Work - Choose one of the following options:
 Probation
Parole
Probation/Parole (combined)
Pretrial Services
Domestic Violence Victim Advocate (community-based)
Victims Services (hired by a justice system agency)
Batterer Program
Criminal Court
Civil Court 		 

Family Court
Prosecutor
Law Enforcement
Defense Bar
Child Protective Services
Substance Abuse Treatment
Mental Health Treatment
Other (Specify)

 
Job Type that best fits your job, or explain in (Other category)  Choose one of the following options:

Administrator
Supervisor
Direct Service Provider (line officer)
Trainer
Other (Specify)

Years on the Job Choose one of the following options:

                    



Approximately what portion of your job responsibilities involve domestic violence cases? Choose one of the following options:

                   

Jurisdiction Type  Choose one of the following options that best describes your agency:

Statewide
County
Municipal
Other (Specify)

Geographic Area of Jurisdiction  Select any of the following options that describe your jurisdiction or service area:

        Urban
        Rural
        Suburban
        Other (Specify)

     
Please indicate if you have already received a copy of this cd training.          No    Yes

 

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Revised: 03/05/08