Victim Services - Victim Survey

Are you a victim of impaired driving?

Yes No

Is this the first time that you are visiting our web page?

Yes No

Is there anything that you would like to see on our website
that would be helpful to you?

Yes No

If Yes, please explain:

Would you like to receive information relating to Victim
Issues from MADD Canada?

Yes No

If Yes, please provide the following information:

First Name:
Last Name:
Address:
City:
Province:	Please select your Province Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Nunavut Ontario Prince Edward Island Saskatchewan Quebec N.W.T Yukon
Postal Code:
Email:

Thank you for taking the time to complete our survey. If ever we can be of assistance do not hesitate to contact Gloria Appleby at 1-800-665-6233 ext. 222; email gappleby@madd.ca