Fillable Address Confidentiality Program Application Assistant Agreement (Columbia Gorge Community College)

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Address Confidentiality Program Application Assistant Agreement (Columbia Gorge Community College)

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Address Confidentiality Program
Application Assistant Agreement
Address Confidentiality Program Phone: 503-373-1323
PO Box 1108 Fax: 503-373-1340
Salem, OR 97308 acp@doj.state.or.us
Name:
Agency Name (published on ACP website):
Agency Mailing Address (published on ACP website):
City(published on ACP website):
Zip Code (published on ACP website):
County (published on ACP website):
Advocate Email:
Advocate Phone:
Supervisor Name:
Agency Phone (published on ACP website):
Do you provide direct services to victims of DV, SA, stalking and/or human trafficking (select one)?
YES NO
Do you provide comprehensive safety planning to victims of DV, SA, stalking and/or human trafficking (select one)?
YES NO
Date and name of agency where you completed a minimum of 40 hours in person DV/SA advocacy training:
Date (mm/yy): Agency:
Date and name of trainer where you completed ACP Application Assistant training:
Date (mm/yy): Trainer:
Languages other than English:
As an Application Assistant, I understand and agree to the following:
• Scope of Work: Adhere to the policies, procedures and directions provided by program staff for rendering
assistance to potentially eligible applicants for the ACP, as well as current participants in the ACP.
• Period of Peformance: The effective date of this agreement is the date of last signature. This agreement shall
terminate two (2) years from the effective date, unless terminated as provided herein. An agreement may be
renewed or reissued for a new two (2) year period upon submission of a request. Contact the ACP office for
a
r
enewal form.
• Nondiscrimination: The Application Assistant agrees not to discriminate against any client, employee or applicant
for employment or services because of race, creed, color, national origin, gender, sexual orientation, age, or
mental, physical or sensory disabilities.
OREGON DEPARTMENT OF JUSTICE
ATTORNEY GENERAL ELLEN F. ROSENBLUM
FOR OFFICE USE ONLY
ACP AA #: ________________
Expires: __________________
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DM3176137v2 Rev. 12/2013
• Application Assistant IS Not A DOJ Employee: The Application Assistant performing under this agreement is not an
employee of the State of Oregon or the Department of Justice, nor is the Application Assistant considered to be an
agent of the State of Oregon or the Department of Justice in any manner whatsoever. The Application Assistan
t
w
ill not hold himself/herself out as, nor claim to be an agent, officer or employee of the Department of Justice or
the State of Oregon by reason hereof and will not make any claim, demand, or application to or for any right or
privilege applicable to an agent, officer or employee of the Department of Justice or the State of Oregon.
• Application Assistant IS Not Responsible for Conduct of Program: The parties recognize that the role of the
Application Assistant is limited to the scope of work specified in this agreement. Application Assistants play no
role in, and bear no responsibility for, the administation of the program.
• Termination: This agreement shall be terminated if the Application Assistant leaves the program/organization
noted on this agreement. The Application Assistant must notify the program upon leaving the
program/organization. At the discretion of the department, a new agreement may be issued upon request by a
trained Application Assistant.
• Termination for Default: The Department of Justice may, by written notice, terminate this agreement in whole or
in part for failure of the Application Assistant to perform any of the provisions hereof.
• Termination for convenience: The Department of Justice may, at its sole discretion, terminate this Agreement for
its convenience upon thirty (30) days’ prior written notice by the Department of Justice to the Application
Assistant.
• Withdrawal of Funds: Should funds budgeted for the Department of Justice be withdrawn or reduced by the
source of those funds, the Department of Justice may, by written notice, immediately terminate this agreement in
whole or in part. The Department of Justice may, in its sole discretion, determine whether a withdrawal of fund
s
r
enders necessary or appropriate the termination of the agreement pursuant to this provision.
• Non-Assignability: The Application Assistant may not delegate any duty, nor assign any right, under this agreement
without the written consent of the Department of Justice.
• Amendment: This agreement may only be amended by the mutual consent of both parties hereto. Any agreement
amendment must be in writing.
• Litigation Venue: This agreement shall be governed by the laws of the state of Oregon, and venue of any suit
between the parties arising out of this agreement shall be the Superior Court of Marion County, Oregon.
• Inclusiveness: This agreement contains the entire agreement of the parties. Any understandings not contained in
this agreement are not a part of this agreement, unless such understandings are written, signed by all parties, and
attached hereto.
Application Assistant:
____
_____________________________________ ________________________
Signature Date
State of Oregon
Acting by and through its Department of Justice:
B
y: __________________________________________ _________________________
Sara Hoffman, ACP Coordinator Date
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Address Confidentiality Program Application Assistant Agreement (Columbia Gorge Community College)

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Completed 28 January 2021

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