Domestic Violence Ambassador Form

Thank you for your interest in becoming an OSE Domestic Violence Ambassador. Please provide the following information:

Email Account Request

Your email account will demonstrate the legitimacy of your role in the organization

Preferred Email Address

(the format “firstname.lastname” or “first_initial.lastname” is recommended)

Do you want messages forwarded to another email address?
If yes, what is the alternate email address?

You will be able to access your email via webmail at

If you would like to configure your Email client manually, use the following information:

Incoming server (IMAP)

Incoming server (POP)

Outgoing server (SMTP)

Slack Account

Slack is an online collaboration tool that allows ambassadors and other team members to collaborate and share resources in real time. It can be accessed at

Preferred Email Address (for Account Login)
Business Cards
Please send me business cards
Preferred Name
Phone Number
Comments / Notes