Crime Victim Registration Form
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CRIME VICTIM REGISTRATION FORM
Please check one:
New Registration
Today’s Date _____________________
Change of Address
Information Correction
Reading Region Change
Completing this form will:
Ensure that your loved one’s name will be read at one of the services.
Ensure that you will receive a Memorial Service invitation.
PLEASE TYPE OR PRINT CLEARLY
Name of Victim:
Date of Death (or Disappearance):
Death Caused By:
County Where Incident Occurred:
Please check ONE of the regions listed below where you will be attending and would like your loved one’s
name read.
( ) Northern Region
( ) Southern Region
( ) Eastern Region
( ) Western Region
Anne Arundel
Calvert
Caroline
Allegany
Baltimore City
Charles
Dorchester
Carroll
Prince George’s
Baltimore County
Kent
Frederick
St. Mary’s
Queen Anne’s
Cecil
Garrett
Harford
Somerset
Montgomery
Howard
Talbot
Washington
Wicomico
Worcester
Your Name: ________________________________________________________________________
Street Address: ______________________________________________________________________
City: _______________________________ State: ______________ Zip Code: ___________________
Phone Number: _____________________________Cell: _____________________________________
Email: ______________________________________________________________________________
USE THIS FORM FOR: 1) New Registration, 2) Change in Address, Contact Information, or
Change in Reading Location. 3) Grammatical or spelling error in a victim’s name.
All other submissions – contact the Juvenile Justice & Victim Services Program Assistant.
Please return this completed form to:
Rebecca Allyn
Juvenile Justice & Victim Services Program Assistant
Governor’s Office of Crime Control & Prevention
100 Community Place, Crownsville, MD 21032
Rebecca.allyn@maryland.gov
S:\AM\CRIME VICTIMS RIGHTS WEEK\Memorial Services\REGISTRATION FORM 2-24-2015
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