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Q 1 Personal
Full Name:
*
Date of Birth
*
MM slash DD slash YYYY
Q 2 Address
Address
*
Street Address
Address Line 2
City
Postal Code
Q3 Communication
Email Address:
*
Mobile Number:
*
Landline Number
Q 4 Preferred Method of Contact
Preferred Method of Contact
*
Phone
Email
Text / WhatsApp
Other:
Relationship to the Troubles
*
Victim / Survivor
Family member of a victim / survivor
Witness
Other:
Which MUVE Services Are You Interested In?
*
Appeals & Tribunal Representation
Advocacy Support
Complementary Therapies
Counselling / Psychological Support
Welfare Support (e.g. financial, housing)
Health & Well-Being Support
Remembrance / Community / Social Activities
Other:
Have You Applied to a Scheme or Process Already?
*
Yes
No
Name of scheme / benefit / service:
Date of application:
MM slash DD slash YYYY
Current status (e.g. awaiting decision, refused, in appeal):
Q 8 Brief Description of What You Need Help With
I consent to MUVE storing and processing my data in accordance with their Privacy Policy.
*
Yes
No
I consent to MUVE contacting me using my preferred method above.
*
Yes
No