Certified Human Trafficking Assistance Organization Application Login Request

Certified Human Trafficking Victim Assistance Organization Application Login Request

Please complete the following form in order to receive login information for the Certified Human Trafficking Assistance Organization application. Once this form is completed, a staff member at the Criminal Justice Coordinating Council will review the request and send the login information to the individuals listed in the submitted form. If you have any questions or issues, please contact Scott Burnett at scott.burnett@cjcc.ga.gov or (404)654-1818.

Agency Name*

Agency Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Director Name*

First Name

Last Name

Director Email*

Director Phone*

Would you like to provide an alternate point of contact for the application?*

Yes No

Alternate Contact Name*

First Name

Last Name

Alternate Contact Email*

Alternate Contact Phone*