Partner Application | PurpleOne Partners

Applicant Information

Please provide information for the individual who will be the primary contact throughout the application process.

First Name*

Last Name*

E-mail Address*

Title

Daytime Phone*

Applying Organization Information

Please enter information relating to the organization/business making the application to become a PurpleOne Partner.

Organization/Business to Become a PurpleOne Partner*

Organization Address 1*

Organization Address 2

City*

State*

Zip Code*

Organization Business Phone*

Organization 24-Hour Hotline Telephone*

Website URL*

Please describe your service area (geographically). For example "Erie County, Pa.", "areas surrounding Erie, PA", "rural Erie County", or "inside the city limits of Erie, PA".*

Please select the option best describes the organization to receive the licence.*

Memorandum of Understanding

If you are not a domestic violence organization affiliated with your state’s coalition against domestic violence that provides comprehensive services, we will require a Memorandum of Understanding (MOU) from a local domestic violence organization in your geographical area in support of your application for our license. PurpleOne requires collaboration and domestic violence expertise. Please upload the MOU below. [You can download a sample MOU at partners.purpleone.org/MOU-template.]

Upload MOU if needed*

Upload

Organization/Leader Criminal History

I agree that neither the applying organization/business (i.e., partner applicant or MOU partners) nor its leaders are currently under investigation or on public record as being convicted of any charges of assault, stalking, other domestic violence-related charges or have been found guilty of any criminal act as outlined in Section 2 of the Reporting of Matters related to Recipient Integrity and Performance of the Office of Violence Against Women as found here: https://www.justice.gov/ovw/file/870606/download.*

AgreeDisagree

Please further explain the circumstances surrounding the criminal accusation or charges.*

For PurpleOne National Office Use Only

Only fill in if you are not human

PurpleOne Partners Application

Applicant Information

Applying Organization Information

Victim Services Provided

Memorandum of Understanding

Organization/Leader Criminal History

Optional Partner Information