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.

EN PARTNERS FORM

Partner Information

Acknowledgement

Nominee Information

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