(a) An adult person, a parent or guardian acting on behalf of a minor, or a guardian acting on behalf of an incapacitated person, who is domiciled in California, may apply to the Secretary of State to have an address designated by the Secretary of State to serve as the personâs address or the address of the minor or incapacitated person. An application shall be completed in person at a community-based assistance program designated by the Secretary of State. The application process shall include a requirement that the applicant shall meet with a counselor and receive orientation information about the program. The Secretary of State shall approve an application if it is filed in the manner and on the form prescribed by the Secretary of State and if it contains all of the following: (1) If the applicant alleges that the basis for the application is that the applicant, or the minor or incapacitated person on whose behalf the application is made, is a designated health care provider, employee, or volunteer, who is fearful for their safety or the safety of their family because of their affiliation with a designated health care services facility, the application shall be accompanied by all of the following: (A) Documentation showing that the individual is to commence employment or is currently employed as a provider or employee at a designated health care services facility, or is volunteering at a designated health care services facility. (B) One of the following: (i) A certified statement signed by a person authorized by the designated health care services facility stating that the facility or any of its providers, employees, volunteers, or patients is or was the target of threats, harassment, or acts of violence or harassment within one year of the date of the application. A person who willfully certifies as true any material matter pursuant to this section that the person knows to be false is guilty of a misdemeanor. (ii) A certified statement signed by the employee or patient of, or volunteer for, the designated health care services facility stating that they have been the target of threats, harassment, or acts of violence within one year of the date of the application because of their association with the designated health care services facility. A person who willfully certifies as true any material matter pursuant to this section that the person knows to be false is guilty of a misdemeanor. (iii) A workplace violence restraining order described in Section 527.8 of the Code of Civil Procedure, issued after a noticed hearing, or a civil restraining order described in Section 527.6 of the Code of Civil Procedure, issued after a noticed hearing, protecting the applicant or the minor or incapacitated person on whose behalf the application is made. The order must be based upon threats or acts of violence to the applicant or the minor or incapacitated person on whose behalf the application is made and connected with the designated health care services facility. (C) A sworn statement that the applicant fears for their safety or the safety of their family, or the safety of the minor or incapacitated person on whose behalf the application is made due to their affiliation with the designated health care services facility authorized to provide the declaration described in subparagraph (B). (2) If the applicant alleges that the basis for the application is that the applicant is a designated health care services facility volunteer, the application shall, in addition to the documents specified in paragraph (1), be accompanied by documentation by the designated health care services facility showing the length of time the volunteer has committed to working at the facility. (3) If the applicant alleges that the basis of the application is that the applicant, or the minor or incapacitated person on whose behalf the application is made, is a person who is or has been the target of threats or acts of violence because the applicant is obtaining or
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