Our primary mission is to provide support to the victims of domestic violence and abuse.

Our secondary mission is to prevent any further violence to the victim.

Our final mission is to assist the victim through the legal system.

Public Areas

Home Page About Us Christmas Wishes Contact Us

Web Stores

Departments

Accounts Dept Clients Area Human Resources Dept Legal Dept Marketing Dept Newsletter Dept Projects Dept Testimonials Dept

IT Services

Home Page Charitable Auto Res Foundation Center GiftWorks User Group GiveLine Good Search Grant Resource Guide Grant Station Guide Star iContact NTEN Post A Need Pet Finder Tech Soup TANO The Animal Rescue Site Vertical Response

The "Circle Of Life" binds us all together as brothers and sisters. Let us heed that call before it is to late !!!

We are the ONLY Nationwide Non-Religious based Domestic Violence Shelter that offers assistance to everyone regardless of their age, race, color, creed, sexual preference, religious beliefs, spiritual practices or alternative lifestyle.

Prospect Request Form

Your ID Number Will Be Validated by the Issuing agency
A Fictitious Number will DENY the Prospect Applicaton Process INSTANTLY !!!

Name: First, Last	,
Address
City, State, Zip	,
Home, Cell, Fax
Email Address:
Birth Date:
Id Type/State, Number:	State ID DLNum Passport
Maritial Status, Children
Maiden Name, Aliases
STD, Health Status	,
Vehicle Yr, Make, Model
Vehicle Plate State, Number
Police Record (If any)
Emergency Contact, Phone
Referred By, Phone
Per Website URL:
AOL SN, Yahoo SN:

Current Employer
City, State, Zip	,
Work, Fax
Email Address

Any additional information that you feel is pertinent to this request.

By your signature below you authorize the Safe Harbor Foundation to investigate your background with these sources. Sources include, but are not limited to NCIC, Mental Health Facilities, Local Police Departments (when available), FBI and DEA agency checks.

Public Areas

Web Stores

Departments

IT Services

Prospect Request Form

Name: First, Last

Address

City, State, Zip

Home, Cell, Fax

Email Address:

Birth Date:

Id Type/State, Number:

Maritial Status, Children

Maiden Name, Aliases

STD, Health Status

Vehicle Yr, Make, Model

Vehicle Plate State, Number

Police Record (If any)

Emergency Contact, Phone

Referred By, Phone

Per Website URL:

AOL SN, Yahoo SN:

Current Employer

City, State, Zip

Work, Fax

Email Address

Any additional information that you feel is pertinent to this request.