PurpleOne - **Safe Place for Domestic Violence Victims Application (and Authorization and Release) Form

Safe Place for Domestic Violence Victims Application Form

This form is an application to become a Safe Place and contains an authorization and release as well as an agreement between PurpleOne and the organization you represent, which is listed below.

The individual listed in this form labeled "PurpleOne Designee" will be the Primary Contact for your organization and must have satisfactorily completed the PurpleOne Training and will educate your staff on what to do if and when a victim of domestic violence enters your physical location. If the trained designee leaves the organization and/or is unable to fully implement the program for any reason, another individual must attend the training within 60 days of the designee being unable to fulfill their duties (or the next available PurpleOne Training date, whichever comes first) to ensure your organization remains a Safe Place and to ensure the integrity of this program and that victims are provided excellent service.

Completion of this application does not guarantee acceptance of the business as a Safe Place for Domestic Violence Victims. Approval/denial will be communicated to the applicant within 15 business days. You may also complete this form and email the completed form to info@purpleone.org or mail to: PurpleOne – PO Box 208 – Union City, PA 16438.

Questions? Please call 814.616.2330 or email info@purpleone.org.

First Name*

Last Name*

PurpleOne Partner*

Who did you take your PurpleOne Training from? At least one person from your organization must have received training in order for you to apply to become a Safe Place.

Safe Place Training Date*

This is the date you took the Safe Place training

Company Name*

Are you representing a company? If yes, complete this field with your official company name. If you are not representing a company, then just leave the company field blank.

Address Line 1*

City*

State / Province*

ZIP / Postal Code*

Use of Company Name*: For good and valuable consideration, the receipt of which is hereby acknowledged, Company (defined above) hereby gives permission to PurpleOne and PurpleOne (defined above) and its successors, assigns, and licensees, to use the Company's name and directory information (address, email, contact person and phone) as well as Company's logo(s) in directory listing on print and digital materials and on the Safe Place Finder for Domestic Violence Victims at purpleone.org, the PurpleOne Safe Place Finder app, or any future iteration of PurpleOne's website or marketing materials.

Use of Company Name*

Agree

Disagree

PurpleOne Training Understanding*: The PurpleOne Training alone does not make or certify me or my organization as a domestic violence counselor, agency or service provider. The undersigned acknowledges that the organization is not by this training alone authorized to represent itself as a domestic violence service provider and is to refer victims of domestic violence to the state-recognized agency that is most appropriate for the victim.

PurpleOne Training Understanding*

Agree

Disagree

Listing Agreement:* The Company agrees to be listed as a PurpleOne Safe Place as displayed and/or broadcast for any purpose in any and all media throughout the world, without limitation as to duration or frequency of usage, in perpetuity and royalty free, for any purpose, including but not limited to directory listings, editorial, advertising, and promotion. It is understood that PurpleOne shall have the right but not the obligation to make use of the Company name, directory information and/or logos as permitted hereunder.

Company Listing Agreement*

Agree

Disagree

Terms of Agreement

PurpleOne Safe Places for Domestic Violence Victims must agree to the following terms in order to provide the highest level of care and support to the victim and for the safety of the business. The businesses' inability to agree to these terms will prevent the business from being part of the Safe Place Network.

Company Full Authority:* Company hereby waives any rights to inspect and/or approve the materials incorporating the Name, directory information and/or logo. The undersigned hereby warrants and represents that he/she has the full right and authority to enter into this agreement concerning the Company name, directory information and logo and that PurpleOne does not need the consent or permission of any other person, firm or corporation in order to use the Company name, directory information and/or logo as described above.

Undersigned Has Authority*

Agree

Disagree

Company Not Providing DV Services:* For the safety of the victims seeking referrals at Safe Places, a company that is not a state-recognized domestic violence agency agrees not to provide or promote their company as providing domestic violence services. Companies with a formal memorandum of understanding with a state-recognized domestic violence agency to provide domestic violence services to their clientele and promoting their business as such will be considered.

Company is not Providing DV Services*

Agreee

Disagree

No Convictions of Company Leadership:* 15.The company acknowledges that neither the designee nor a member of the organization's leadership is on public record as being convicted on charges of assault, stalking, or other domestic violence-related charges.

No Convictions of Company Leadership*

Agree

Disagree

Company Indemnification:* Company shall indemnify and hold harmless PurpleOne (including its members, officers, representatives, and employees) against any loss, liability, claim, demand, or expense (including court costs and attorneys' fees) including any claim arising out of PurpleOne's negligence, arising out of or in connection with the PurpleOne training or Company's designation as a Safe Place. These indemnities shall survive the termination of this Agreement.

Company Indemnification*

Agree

Disagree

PurpleOne Designee Main Point of Contact:* The individual who attended the PurpleOne training will be the PurpleOne Designee and will be the main point of contact and responsible for communicating to your staff what to do if victims enter your establishment looking for information. If the trained designee leaves the organization and/or is unable to fully implement the program another individual must attend the training within 60 days of the designee being unable to fulfill their duties (or the next available training date, whichever comes first) to ensure your organization remains a Safe Place and to ensure the integrity of this program and that victims are provided excellent service.

PurpleOne Designee*

Agree

Disagree

PurpleOne Designee / main person of contact (If this is you, please enter your name)

PurpleOne Designee Person Work Phone*

PurpleOne Designee Person Primary Email*

Authorized Company Representative

Authorized Company Representative Name*

Title of Authorized Company Representative*

Email of Authorized Company Representative*

Signature Block

Type the Name of the Authorized Company Representative to Electronically Sign This Authorization and

Signature Block

By typing or signing your name below, you are acknowledging that you (1) are an authorized representative and signer for the business listed above and (2) agree to the statements and terms listed above. Upon submission of this form, you will have the opportunity to print or download a PDF of the form. Further, an email receipt will be sent to the Email Address of Authorized Company Representative. This receipt does not guarantee acceptance of the business as a Safe Place for Domestic Violence Victims. Approval/Denial will be communicated to the applicant within 10 business days.