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(800)-213-ETRS | Wayne County: 734-462-3096 | Oakland County: 248-399-2600

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Men’s GRANT FUNDED Domestic Violence Orientation STAFF

If there is a no-show for a grant-funded evaluation, the individual will be charged $50 to reschedule.

"*" indicates required fields

Men's Domestic Violence Orientation CHOOSE DAY/TIME

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Men’s GRANT FUNDED Domestic Violence Orientation STAFF

First Name*

Last Name*

Date of Birth*

Month

Day

Year

Court*

Are you an MDOC client or a Private client?*

MDOC Client

Private (non-MDOC) Client

Please enter your MDOC number:*

Probation Officer Name*

Case Number

Your Email Address*

Your Zip Code*

ZIP / Postal Code

Your Phone Number*

B.A.C. (if it was an alcohol offense)

Do you have any prior offenses?

yes

no

If yes, how many?

Product Name

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Men’s GRANT FUNDED Domestic Violence Orientation STAFF quantity

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