Mailing List And Membership Form

Mailing List & Membership Form

Please fill out the fields below to be added to our mailing list and/or membership list. All fields marked with a red asterk (*) are required to be added to our mailing list all other fields are optional.

Please provide the following contact information for our mailing list:

**Contact Information**
*First name
*Last name
Middle initial
Title
Organization
*Street address
Address (cont.)
*City
*State/Province
*Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
Web Site Address

Choose one of the following options:

Please provide the following information for our survivor membership list.

Homicide Survivors who live in New Mexico or who's loved ones were murdered in New Mexico please fill out the following if you would like your loved one(s) added to our database. If you have lost more then one loved one to homicide please fill out this form for each victim.

**Decedent Information**
Decedent First
Decedent Middle
Decedent Last
Date of Birth
Date of Homicide
City & State of Hoimicide
Your relationship with the decedent