(a)    The following individuals may apply to participate in the Program:

(1)    an individual acting on the individual’s own behalf;

(2)    a parent or guardian acting on behalf of a minor who resides with the parent or guardian; or

(3)    a guardian acting on behalf of a disabled person.

(b)    An application to participate in the Program shall be in the form required by the Secretary of State and shall contain:

(1)    a statement that:

(i)    the applicant is a victim of human trafficking; and

(ii)    the applicant fears for the applicant’s safety or the safety of the applicant’s child;

(2)    evidence that the applicant is a victim of human trafficking, including:

(i)    certified law enforcement, court, or other federal or State agency records or files;

(ii)    documentation from a human trafficking prevention or assistance program; or

(iii)    documentation from a religious, medical, or other professional from whom the applicant has sought assistance or treatment as a victim of human trafficking;

(3)    a statement that disclosure of the applicant’s actual address would endanger the applicant’s safety or the safety of the applicant’s child;

(4)    a knowing and voluntary designation of the Secretary of State as agent for purposes of service of process and receipt of first–class, certified, or registered mail;

(5)    the mailing address and telephone number at which the applicant may be contacted by the Secretary of State;

(6)    the actual address that the applicant requests not be disclosed by the Secretary of State because it would increase the risk of human trafficking or other crimes;

(7)    a sworn statement by the applicant that, to the best of the applicant’s knowledge, all the information contained in the application is true;

(8)    the signature of the applicant and the date on which the applicant signed the application; and

(9)    a voluntary release and waiver of all future claims against the State that may arise from participation in the Program except for a claim based on gross negligence.

(c)    (1)    (i)    On the filing of a properly completed application and release, the Secretary of State shall:

1.    review the application and release; and

2.    if the application and release are properly completed and accurate, designate the applicant as a Program participant.

(ii)    An applicant shall be a participant for 4 years from the date of filing unless the participation is canceled or withdrawn prior to the end of the 4–year period.

(2)    A Program participant may withdraw from participation by filing a signed, notarized request for withdrawal with the Secretary of State.