Harrison County TRIAD/SALT Request Form



Harrison County TRIAD

Request Form

Last Name ______________________________________Date_____________

Address _________________________________________________________

City ________________________ State MS Zip code 395 _ _ County Harrison

Phone ( ) ______-____________ Alt phone ( ) ______-____________

|Client #1 |Client #2 |

|Name |Name |

|Date of Birth Age |Date of Birth Age |

|Medical / physical limitations? Yes / No |Medical / physical limitations? Yes / No |

|Are you a veteran? Yes / No |Are you a veteran? Yes / No |

|Are you a veteran spouse? Yes / No |Are you a veteran spouse? Yes / No |

|Are you interested in the RUOK Program? Yes / No |Are you interested in the RUOK Program? Yes / No |

*ALL ITEMS ARE FREE OF CHARGE*

PLEASE PLACE AN “X” IN THE BOX TO THE LEFT OF THE ITEMS YOU SELECT.

( ) FILE OF LIFE (one each)

( ) REFLECTIVE ADDRESS SIGN

( ) Mailbox ( ) House ( ) Fence ( ) Other ( ) Vertical ↕ ( ) Horizontal ↔

( ) Other ____________________________________________________

MAIL FORM TO:

Harrison County Sheriff Department

ATTN: TRIAD

P.O. Box 1480

Gulfport, MS 39502

For more information, contact Lieutenant Robert Lincoln Community Relations Officer.

(228) 896-0614 or TRIAD@

Revised 7-2017

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Volunteer assigned ________________________

Date Items Installed________________________

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