Business Connection Application Form

BUSINESS CONNECTION APPLICATION FORM

Parties and Recitals

WHEREAS, Applicant Name: (the "Applicant") seeks to establish a commercial connection and business relationship to obtain access to goods, services, or technical integration offered by Service Provider Name: (the "Provider");

WHEREAS, the parties intend to set forth the scope, responsibilities, financial terms and confidentiality protections that will govern the proposed business connection and any related services;

NOW, THEREFORE, Applicant and Provider agree that the Applicant's request for a business connection and any resulting supply or service arrangement shall be governed by the terms set forth in this Application and the resulting Agreement upon acceptance by the Provider.

Business Information (Applicant)

Sole Proprietorship    Partnership    Corporation    Limited Liability Company (LLC)    Other:

Requested Connection Details

Scope of Work

Describe the services, products, deliverables, technical interfaces, obligations and acceptance criteria that will define the business connection. Include any timelines, milestones and performance metrics that the Applicant expects the Provider to meet.

Payment Terms

Fee Amount: — specify the agreed currency and whether amounts are exclusive of taxes.

Late Payment: If any undisputed amount is not paid when due, interest will accrue at the lesser of 1.5% per month or the maximum rate permitted by applicable law, plus the reasonable costs of collection including attorneys' fees.

Term and Termination

Term Commencement Date: .

Term Expiration Date (if any): . Absent an expiration date, the arrangement will continue until terminated in accordance with this section.

Either party may terminate for convenience upon written notice to the other delivered at least days prior to the effective termination date. Either party may terminate immediately for material breach that remains uncured for thirty (30) days after written notice, or immediately for insolvency or bankruptcy of the other party.

Confidentiality

Each party acknowledges that, in the course of negotiation and performance, it may receive Confidential Information of the other. "Confidential Information" means non-public business, technical, financial or other information disclosed in any form. The recipient will (a) use Confidential Information solely for the purposes of evaluating or performing the business connection; (b) restrict disclosure to its employees, agents or contractors with a need to know who are bound to protect it; and (c) not disclose Confidential Information to third parties without prior written consent, except as required by law. Confidentiality obligations shall survive termination for a period of three (3) years, except trade secrets which shall be protected for as long as they remain trade secrets.

Representations, Warranties and Compliance

Applicant represents and warrants that the information provided in this Application is true, complete and correct, that it has the authority to enter into the proposed arrangement, and that it will comply with all applicable laws, regulations and Provider policies in connection with the business connection.

Governing Law and Dispute Resolution

This Application and any resulting Agreement shall be governed by and construed in accordance with the laws of the State or Jurisdiction of Governing Law: , without regard to conflict of law principles. The parties shall attempt to resolve disputes in good faith through negotiation; if unresolved within sixty (60) days, either party may pursue any available remedies in the courts of the governing jurisdiction.

Entire Agreement

This Application and any fully executed written Agreement referencing this Application constitute the entire understanding between the parties with respect to the subject matter and supersede all prior or contemporaneous agreements, representations or communications, whether written or oral. Any amendment must be in writing and signed by authorized representatives of both parties.

Applicant Certification

By signing below, Applicant confirms that the information contained in this Application is true and complete to the best of its knowledge, that Applicant has authority to bind the business entity, and that Applicant accepts the terms and conditions set forth herein as the basis for pursuing the requested business connection.

Additional Information / Attachments

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