V.A.N. (Victims Assistance Network) Form
Please provide details regarding the V.A.N. request, and a CLIF representative will contact you within 48 hours.
Email address *
Name of Recommender *
Your answer
Email of Recommender *
Your answer
Date *
MM
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DD
/
YYYY
Name of Recipient *
Your answer
Email of Recipient
Your answer
Address (location for care package, if applicable)
Your answer
Phone Number of Recipient *
Your answer
Services Requested: *
Required
Please provide specific details regarding car crash (date of crash, location, individuals involved, cause of crash, injuries, media story links, etc) and the recipient. *
Your answer
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