{"id":82,"date":"2024-10-01T00:11:34","date_gmt":"2024-10-01T00:11:34","guid":{"rendered":"https:\/\/depts.washington.edu\/ago-forms\/?page_id=82"},"modified":"2024-10-01T00:13:36","modified_gmt":"2024-10-01T00:13:36","slug":"affiliation-agreement-review-request-form","status":"publish","type":"page","link":"https:\/\/depts.washington.edu\/ago-forms\/affiliation-agreement-review-request-form\/","title":{"rendered":""},"content":{"rendered":"<p><script type=\"text\/javascript\">var 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n<div class='gform_heading'>\n<h2 class=\"gform_title\">Affiliation Agreement Review Request Form<\/h2>\n<p class='gform_description'>The Attorney General\u2019s Office (AGO) performs an \u201cApproved as to Form\u201d review of affiliation agreements. This is a limited review that ensures an agreement meets the basic requirements of a legally binding contract; it does not imply concurrence in or approval of the desirability or wisdom of the transaction or agreement. Depending on the complexity of the agreement, review may take up to 30 days. Because the AGO is not a party in affiliation agreements, the AAG\u2019s signature is not required. This form and process is solely for review of draft Affiliation Agreements. If other legal or drafting assistance is requested, please email ali.maki@atg.wa.gov.<\/p>\n<\/p>\n<\/div>\n<form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/ago-forms\/wp-json\/wp\/v2\/pages\/82' data-formid='2' novalidate>\n<div class='gform-body gform_body'>\n<div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_above validation_below'>\n<fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n<p>                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label><br \/>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/><br \/>\n                                                <\/span><\/p>\n<p>                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                            <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label><br \/>\n                                                            <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/><br \/>\n                                                        <\/span><\/p>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_2_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_2_2_container'>\n                                <span id='input_2_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'><br \/>\n                                    <label for='input_2_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label><br \/>\n                                    <input class='' type='email' name='input_2' id='input_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/><br \/>\n                                <\/span><br \/>\n                                <span id='input_2_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'><br \/>\n                                    <label for='input_2_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label><br \/>\n                                    <input class='' type='email' name='input_2_2' id='input_2_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/><br \/>\n                                <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p>\n<\/div>\n<\/fieldset>\n<div id=\"field_2_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><label class='gfield_label gform-field-label' for='input_2_5'>Internship\/Rotation Start Date (MM\/DD\/YYYY):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='large' maxlength='20'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_2_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\" ><label class='gfield_label gform-field-label' for='input_2_21'>Training Site Location (city, state)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<fieldset id=\"field_2_8\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Expedited Review?<\/legend>\n<div class='gfield_description' id='gfield_description_2_8'>If rotation is starting in less than 4 weeks and expedited review is necessary, please check the box below.<\/div>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_2_8'>\n<div class='gchoice gchoice_2_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Expedited review'  id='choice_2_8_1'   aria-describedby=\"gfield_description_2_8\"\/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_1' id='label_2_8_1' class='gform-field-label gform-field-label--type-inline'>Expedited review<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_2_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" >\n<h3 class=\"gsection_title\">Parties<\/h3>\n<\/div>\n<div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>UW School\/Program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large' maxlength='50'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label' for='input_2_11'>Affiliate (the other party\/not UW)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large' maxlength='70'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_2_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><label class='gfield_label gform-field-label' for='input_2_12'>Other<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='large' maxlength='100'     aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_2_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><label class='gfield_label gform-field-label' for='input_2_15'>If you selected &quot;Other&quot;, please specify<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large' maxlength='50'     aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<fieldset id=\"field_2_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Signatories<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_2_24'>\n<div class='gchoice gchoice_2_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='The names and titles of all signatories for the attached document(s) are filled out.'  id='choice_2_24_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_1' id='label_2_24_1' class='gform-field-label gform-field-label--type-inline'>The names and titles of all signatories for the attached document(s) are filled out.<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_2_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='The document(s) can&#039;t be edited. Signatory names and titles are included in the Comments section below.'  id='choice_2_24_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_2' id='label_2_24_2' class='gform-field-label gform-field-label--type-inline'>The document(s) can&#8217;t be edited. Signatory names and titles are included in the Comments section below.<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_2_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" >\n<h3 class=\"gsection_title\">Is this AA based on a UW template or the affiliating party&#039;s?<\/h3>\n<div class='gsection_description' id='gfield_description_2_13'>*If this is a renewal or an amendment, please attach copies of prior agreement(s). <\/div>\n<\/div>\n<div id=\"field_2_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\" ><label class='gfield_label gform-field-label' for='input_2_20'>Please select an option below<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_select'><select name='input_20' id='input_2_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='UW' >UW<\/option><option value='Affiliating Party' >Affiliating Party<\/option><option value='Other' >Other<\/option><\/select><\/div>\n<\/div>\n<fieldset id=\"field_2_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >This is a:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_2_16'>\n<div class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='New affiliation'  id='choice_2_16_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>New affiliation<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Renewal of a previous agreement'  id='choice_2_16_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Renewal of a previous agreement<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_2_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Amendment of a previous agreement'  id='choice_2_16_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_3' id='label_2_16_3' class='gform-field-label gform-field-label--type-inline'>Amendment of a previous agreement<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_2_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='MOU\/Other'  id='choice_2_16_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_4' id='label_2_16_4' class='gform-field-label gform-field-label--type-inline'>MOU\/Other<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><label class='gfield_label gform-field-label' for='input_2_17'>If you selected MOU\/Other, please specify.<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large' maxlength='65'     aria-invalid=\"false\"   \/> <\/div>\n<\/div>\n<div id=\"field_2_3\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Comments<\/label><\/p>\n<div class='gfield_description' id='gfield_description_2_3'>(Please detail any negotiation efforts, concerns, or specific questions* here)<\/p>\n<p>*Questions regarding insurance coverage should be directed to Risk Services.\n<\/p>\n<\/div>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_3' id='input_2_3' class='textarea medium'  aria-describedby=\"gfield_description_2_3\" maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<fieldset id=\"field_2_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Exhibits\/Addendums<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_2_26'>\n<div class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Any Exhibit(s) or Addendum(s) referenced in the AA are included.'  id='choice_2_26_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>Any Exhibit(s) or Addendum(s) referenced in the AA are included.<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_2_19\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\" ><label class='gfield_label gform-field-label' for='gform_browse_button_2_19'>Attachments<\/label><\/p>\n<div class='gfield_description' id='gfield_description_2_19'>If this is a renewal or amendment, please attach copies of prior agreement(s).<\/div>\n<div class='ginput_container ginput_container_fileupload'>\n<div id='gform_multifile_upload_2_19' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_2_19&quot;,&quot;container&quot;:&quot;gform_multifile_upload_2_19&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_2_19&quot;,&quot;filelist&quot;:&quot;gform_preview_2_19&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/depts.washington.edu\\\/ago-forms\\\/?gf_page=f92b2125dae7a93&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/depts.washington.edu\\\/ago-forms\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/depts.washington.edu\\\/ago-forms\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed 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