Empowered Network | Partners Form

GET INVOLVED > PARTNERS FORM

EN PARTNERS FORM

Please fill out the form entirely!

* indicates required fields

Partner Information

EN Staff who completed consultation *

Please choose one from the list

Partner Contact Email *

Partner Completing Form *

Date of Nomination *

Acknowledgement

I CERTIFY THE FOLLOWING NOMINEE IS (check to agree): *

Is a human trafficking survivor as defined by TVAP of 2000
Is sober ( 6 months minimum)
Is not in crisis
Is stable
Is working or equivalent
Is ambitious and "ready" for the accountability program

Nominee Information

Name of Survivor *

This is kept confidential with EN staff

Survivor Email *

Survivor Phone *

Is nominee currently enrolled in one of the following? *

Has nominee received any of the following funding in the past? *

Why are you nominating this survivor to EN?

EN Location *

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Signed by point person for agency listed in MOU *

Enter initials above

By signing this nomination form, you attest that all details are accurate, and you have read and understand the operational agreement between our organization and EHN.

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EN PARTNERS FORM

Partner Information

Acknowledgement

Nominee Information

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