Application Deadline: 03/15/2013
Seating is limited. Applicants will be notified of their acceptance by email.
STUDENT APPLICATION
Please type or print legibly. If additional space is required please attach separate sheets.
Name:
Organization/Agency:
Address:
City:
State:
Zip:
Telephone:
Fax:
E-mail:
Current Position:
Paid:  Volunteer:  Student: 
Supervisor Name:
Telephone:
Email:
How long have your worked in a career
field interacting with victims?
Years:
Months:
1. Which of the following best describes the field in which you work?
 Victim Services
 Corrections/Probation
 Education
 Law Enforcement
 Human Services
 Other (please specify)
 Prosecution
 Healthcare Professional
 Courts  Student (if you are a student, skip questions 2-4 and proceed to Section 2)
2.



Which of the following best describes your agency?
Non-Profit Agency
 State Government
City Government
 Federal Government
County Government
 Tribal Agency
 Private, for profit agency
 Other (please specify)
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3.






Indicate your primary area(s) of interest:
Assault
 Hate/Bias Crimes
Child Abuse
 Homicide
Domestic Violence
 Identity Theft
Drunk/Drugged Driving  Kidnapping/Missing Persons
Elder Abuse
 Property Crimes
Fraud
 Sexual Violence




Stalking
Trafficking
No primary area of focus
Other (please specify)
Section 2:
Briefly describe your reason for attending the Victim Assistance Academy for North
Dakota training and define how your participation will be of personal, professional, and
community benefit. Briefly summarize your current and previous experience assisting
victims of crime.
Section 3:
Briefly summarize your current and previous experience assisting victims of crime.
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Section 4:
Please provide any additional information you believe important for the application
selection committee to consider. If you are a college student, please also include your
major field of study and your college education level.
Section 4: (College students, skip to Section 5)
A letter of recommendation is required for selection to the Victim Assistance Academy
for North Dakota. The letter must be from your department or agency supervisor
authorizing your attendance and confirming their commitment to your training. College
students must have a letter from a college instructor / professor or advisor.
This letter must be submitted with the application.
Accommodations:
Special Requirements:
Food:
Access:
By completing and signing this application, I verify that all information given is accurate
to the best of my knowledge and that any false information will be sufficient cause for
rejection of my application. Also, in signing this application I verify my commitment to
attend the full course, provide verification of on-line coursework, and to make travel
arrangements accordingly.
Applicant Signature
Date
Supervisor Signature
Date
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FEES:
The cost to students for registration, course materials, and operational costs is $100. For
the 2013 VAAND, mileage, lodging, and a portion of the per diem will be covered by
VAAND along with all course materials. Students will be instructed on how to
complete a reimbursement form for expenses at the Academy.
Fees are not due until notification of acceptance.
APPLICATIONS MUST BE RETURNED BY 4:30 PM, FRIDAY, MARCH 15, 2013
PLEASE E- MAIL YOUR COMPLETED APPLICATION FORM TO:
Shelly Carlson at
Michelle.a.carlson@minotstateu.edu
QUESTIONS:
If you have any questions or need additional information, please call:
Rural Crime and Justice Center
VAAND – Shelly Carlson
Phone: 701-858-4127
Email: michelle.a.carlson@minotstateu.edu
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