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Attachment B
<br />Appendix D. Sample host site agreement
<br />The actual agreement is subject to change based on updated CNCS/AmeriCorps policies for the
<br />2019-2020 program year.
<br />MMINNESOTA POLLUTION Minnesota GreenCorps
<br />CONTROL AGENCY
<br />520 Lafayette Road North host site agreement
<br />St. Paul, MN 55155-4194
<br />Program Year 2017 - 2018
<br />Doc Type: Agreement
<br />C)
<br />GreenCorps CR #:
<br />SWIFT #:
<br />I. Purpose
<br />This Agreement is between the State of Minnesota, acting through its Commissioner of the Minnesota Pollution Control
<br />Agency (MPCA), 520 Lafayette Road North, St Paul, MN 55155, using the Minnesota GreenCorps Program, herein
<br />after referred to as "State" or "MPCA," and <Insert host site name and address>, herein after referred to as the "Host
<br />Site." The Agreement delineates the terms, conditions, and rules of participation in the Minnesota GreenCorps Program
<br />for the 2017-2018 program year.
<br />II. Term of agreement
<br />Effective date: September 13, 2017, or the date the State obtains all required signatures under Minn. Stat. § 16C.05,
<br />subd. 2, whichever is later.
<br />Expiration date: August 14, 2018, or until all obligations have been satisfactorily fulfilled, whichever occurs first.
<br />III. Authorized representatives
<br />The MPCA's Authorized Representative is Cristina Villella, Minnesota GreenCorps Program Coordinator, 520 Lafayette
<br />Road North, St Paul, MN 55155, 651-757-2580, cristina.villella(a)state.mn.us or her successor.
<br />The Host Site's Authorized Representative is <Name, title, address, telephone number, email>, or his/her successor. If
<br />the Host Site's Authorized Representative changes at any time during this Agreement, the Host Site must immediately
<br />notify the MPCA.
<br />The Host Site supervisor(s) is/are: <Name, title, address, telephone number, email>, or successor.
<br />If the supervisor(s) changes at any time during this Agreement, the Host Site must immediately notify the MPCA.
<br />IV. Member position description
<br />The Host Site, along with listed partners, will provide direction, supervision, and resources for the following Minnesota
<br />GreenCorps member (Member) position (s) <Insert position title>.
<br /><Insert position description>
<br />A. Member eligibility requirements
<br />1. Must be a minimum or 18 years of age or older at the start of the term of service.
<br />2. Must be a U.S. Citizen, U.S. National, or Lawful Permanent Resident Alien of the U.S.
<br />3. Must successfully pass a criminal background search of the National Sex Offender Public Registry, the
<br />Minnesota Bureau of Criminal Apprehension, and the corresponding government entity from their state of
<br />current residence.
<br />4. Must not have a criminal history, as concluded from a fingerprint -based Federal Bureau of Investigation (FBI)
<br />criminal history check, which precludes the member's ability to have recurring access to vulnerable
<br />populations (i.e., children, elderly, and persons with a disability).
<br />5. Must have a High School Diploma/GED
<br />6. Must have completed a two-year Associate of Arts degree or completed sophomore year in a four-year college
<br />program.
<br />Page 24 of 34 I February 2019 1 p-mgc2-03
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