Public Safety, Government, Private Sector Registration
Notification e-mail address must be company / organization affiliated. Please, no personal e-mail addresses. Please complete the form below, no partial applications accepted.
CONTACT INFORMATIONFirst Name *Last Name *Position/Title/Rank: *Phone Work: (###-###-#### - ext) *Mobile Phone: (###-###-####) Email Address: * Use your company/organization addressPlease re-type your email address: *Address: *Address 2:City: *County: *
AGENCY / ORGANIZATIONAgency/Organization Name: *SUPERVISOR CONTACTFull Name*Supervisor's Title*Phone Work:* (###-###-####) Supervisor's Email Address:* (Organization email addresses only)WEBSITE ACCESSPassword: *Create a password for site access / modify your contact information
DESCRIPTION OF FACILITY OR NATURE OF BUSINESS* Description is required to substantiate the need for inclusion in the DVIC
*Required Select "Other" if not applicable
Other Sector (please specify)
All registration information is considered strictly confidential and will not be shared.
I agree to the following terms and conditions: NON-DISCLOSURE AGREEMENT
Intending to be legally bound, I hereby accept the obligation contained in this Agreement in consideration of my being granted access to “sensitive information.” The term, “sensitive information” may include:
For Official Use Only (FOUO): information which warrants a degree of protection and administrative control that meets the criteria for exemption from public disclosure under the Privacy Act, and state and federal Freedom of Information Acts.