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Department of Crime Victim Services

Training, Provider Certification, and Statistical Analysis

Victim Service Provider (VSP) Application

Applicant Contact Information

First Name

Last Name

Agency/Department

Position Title

Agency Physical Address

Suite

City

State

Zip

Applicant Agency Email

Contact Work Phone

Contact Cell Phone

Employment Duration

Number of Paid Employees in Agency

Date of Hire:

County:

Municipality:

Judicial Circuit

Organization Type:

For Credentialing Field, Please select one of the following:

Credentialing:

Basic VSP: Within one year of your start date you must complete the 15-hour basic core training curriculum in order to complete the certification process and become a certified VSP.

Notifier / Support Staff: You must complete the 2-hour Notifier/Support Staff training track every other year to maintain certification as a VSP-N.

VSP-HT: Specialized training for approved Human Trafficking VSPs whose role is solely or primarily providing services to Human Trafficking Victims. Within one year of your start date you must complete the Human Trafficking specialized 15-hour basic training curriculum as required by the Human Trafficking Task Force.

Agency Supervisor Information (Required for Certification)

First Name

Last Name

Position Title

Organization (no abbreviation)

Agency Email

Work Phone

Cell Phone

Notice: VSP certification does not constitute licensure and is not to be construed as a warranty of the applicant's ability to deliver services. The applicant retains sole liability for any consequences stemming from deliberate falsehoods, misrepresentations, or forgeries in this application. The Department of Crime Victim Services Training, Provider Certification and Statistical Analysis (CVST) makes no guarantee that the information in this application is accurate or complete.