National Clearinghouse on
Marital and Date Rape
http://ncmdr.org
mirror site:
http://members.aol.com/ncmdr
CONTACT FORM
Please print, fill out and mail to the
address above!
Join us to be included in our database as subscriber to our information / referral / support Network of Survivors, Activists, Advocates and Allies.
Contact Information
Mail to be sent to (circle one): Home Address / Work Address / Volunteer Address
Type of membership: Individual / Organizational
First name:
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Last:
Nickname:
Name of Member Organization:
Home Information
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Fax:
Email, Website:
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Affiliation / Volunteer Work Information
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Additional Contact Numbers
(Secretary/Receptionist, Vacation
Home, Partner/Children, etc.)
First additional number & type of number:
Second additional number & type of number:
Cellular/car phone:
Voicemail/pager:
Comfortable Contact Hours
Home:
Work:
Volunteer:
Additional Information
Please CIRCLE the areas in your life in which you pursue the following interests:
Marital Rape - Activist / Personal / Professional
Partner Rape - Activist / Personal / Professional
Date Rape - Activist / Personal / Professional
Other Violence - Activist / Personal / Professional
Other Violence Defined (Please list):
Please CIRCLE the areas of expertise you offer (for referral use):
Marital Rape -
Partner Rape - Consult / Testify / Speak
Date Rape - Consult / Testify / Speak
Other Violence - Consult / Testify / Speak
Other Violence Defined (Please list):
Publications Offered (Including handouts):
Involvement - In which of our networking activities would you like to participate?
Legislative | Court | Campus | Media | Workplace | Community | Religious/Spiritual | Other (please explain):
Reference (Where did you hear about NCMDR?):
Relationship - When, where and how
are you now (or have you ever been) associated with NCMDR?
(Circle all that apply)
WORKSHOPS: Campus / Community / Conference /
Worksite / Religious Site
Date and location:
MEMBER: Standard member / Donor /
Supporter ($250) / Angel ($500) / Grantor
Date and location:
CLIENT: Advocacy / Consulting / Strategy
Date and location:
SUBSCRIBER: Information and referral /
Document Delivery / Research
Date and location:
CUSTOMER: "Laws/Facts?books"
($10) / "Licence to Rape" ($20) / Conference Exhibitor
Date and location:
STAFF: Paid / Volunteer or Intern
Date and location:
As a client/subscriber of NCMDR you gain access not only to all of the services of NCMDR (at $7.50 per 15 minutes phone consulation or other time you request, as above), but also, by referral, to the thousands of people in our network through our Database Organizing Project.
Do you wish to support/use our work -- but not wish to be in the database for other member's access? - YES / NO
Do you wish to support our Special Networking/Database Projects (extra-ordinarily under-served groups targeted by perpetrators, including peer perpetrators)? If so, check which projects:
Lesbian-Bi-Gay People / Elders / Teens / People with Disabilities / People of Color
Please join our 32 year volunteer, grassroots local, national international campaigns to end all of the inequalities that foster intimate violence.
CLIENT/SUBSCRIBER
ANNUAL ACCESS FEE:
(circle one)
$10 (Low income) / $15 (Individual) / $30 (Organizations)/ Other / "License to Rape" hardback free with $25 membership
Kindly make checks payable to the following:
For business deductions for phone
consultations/strategy/research/advocacy and publications:
National Clearinghouse on Marital
and Date Rape (NCMDR)
Birth date/day:
Organization anniversary date:
Today's date:
Please print, fill out and mail to the address above!