Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Membership Category (Please select one) *

Member ($30) – Law Enforcement Advocates from Local, State and Federal Agencies

Associate Member ($35) – Representing all other facets of victim services or allied agencies

Payment *

Mail payment to: Marisa Capers SCLEVA Treasurer Lexington Medical Center Department of Public Safety 115 W. Hospital Drive W. Columbia, SC 29169

I will mail a check or money order payable to SCLEVA.