Address Confidentiality Program

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NEW APPLICATIONS

Applicant Name

Phone

Email Address

Status

Submission

APPLICANT SECTION (In Progress by Applicant)

Applicant Name

Phone

Email Address

Created

APPLICATION SUBMITTED TO ACP (APPLICATION HISTORY)

Applicant Name

Phone

Email Address

Status

Submission

Advocate Information

Hide my name on website (yes or no)

First Name Last Name

Position/Title Email

Phone Number Phone Extension

Are you fluent in any language(s) other than English?

If yes, which language(s)?

Agency Information

Agency Name Address

Postal/Zip Code City

State County

Phone Phone Extension

Website Address

Supervisor Information

First Name Last Name

Phone Ext.

Whom does your program serve (check all that apply):*

Domestic Violence

Stalking

Sexual Assault

Human Trafficking

All Crime Victims

Other:(Specify below)

Other Services

Training Completion Date

Acknowledgements

I will provide program information and assistance to potentially eligible participants, including assistance with applications and the enrollment process, when allowed by the funding for my position.

I will attend all required ACP training sessions scheduled by the Department of Attorney General for Application Assistants or Victim Advocates.

I will adhere to ACP's policies, procedures, and directions for assisting eligible participants.

Neither my agency nor I will keep copies, electronic or hard copy, of ACP applications.

I will comply with federal, state, and local laws prohibiting unlawful discrimination.

I will notify ACP if and when I leave my current agency/organization and inform ACP of my new agency/organization and contact information, if I want to continue acting as an ACP assistant.

If I no longer am able or wish to assist ACP applicants, I will notify the ACP and request to be removed from the list of potential assistants.

My certification is valid for 2 years and I may renew for a new 2-year period upon completion of ACP refresher training.