Holodomor Descendants’ Network

Descendant’s Name*
Surname Given Name Maiden Name, if applicable
Hidden
Relationship
Phone*
- Mobile
- Home
- Work
Country Code
Area Code
Number
Email*
Current Country of residence
Names of family members, victims of the Holodomor
Relationship Surname Given Name Maiden Name, if applicable Date of Birth Date of Death
Names of family members, survivors of the Holodomor
Relationship Surname Given Name Maiden Name, if applicable Date of Birth Date of Death Country of residence at time of death
Name of oblast in which your family lived during the Holodomor
Name of City or Village in which your family lived during the Holodomor
LEVEL OF INTEREST:*
- Keep me informed of the activities/newsletters via email ONLY
- I am willing to participate in research on Holodomor descendants
- I am willing to participate actively in the work of the Holodomor Descendants’ Network
- I do not want to be contacted at all
- I would like to connect with my local or regional Holodomor Commemoration Committee
Please indicate by checking all that apply
PRIVACY*
- I do not give my/my family’s identifiable information
- I give you permission to share my/my family’s information
- I give you permission to share my/my family’s information in aggregate or anonymously ONLY

Relationship	Surname	Given Name	Maiden Name, if applicable	Date of Birth	Date of Death

Relationship	Surname	Given Name	Maiden Name, if applicable	Date of Birth	Date of Death	Country of residence at time of death