Business Representations and Certifications Form

Business Representations and Certifications Form

Recitals

WHEREAS, Business Name: is duly organized and authorized to conduct business and seeks to provide goods or services to Recipient Entity: ;

WHEREAS, the parties desire to record the representations and certifications of Business Name and to set forth certain terms governing the provision of goods or services and the reliance placed on such representations; and

NOW, THEREFORE, Business Name makes the following representations and certifications to Recipient Entity as material inducements to entering into any purchase order, agreement or other transaction.

Business Identification

Entity Type

Corporation LLC Partnership Sole Proprietorship Other:

Representations

1. Authority: The signatory has full authority to bind the business to the representations and certifications contained herein.

2. Organization and Standing: The business is duly organized, validly existing and in good standing under the laws of its jurisdiction of organization and has the power to perform its obligations.

3. No Conflicts; No Proceedings: Execution and performance will not violate any agreement or order to which the business is a party or result in any pending or threatened proceeding that would materially impair performance.

4. Tax and Regulatory Compliance: The business has filed all tax returns required, has paid all taxes due or has provided for payment, and is not currently debarred, suspended or otherwise ineligible to transact with third parties under applicable law.

5. Insurance: The business maintains insurance coverage customary for its industry and appropriate to the services to be performed.

Certifications

By checking each box below the business certifies as true and correct as of the date of signature:

a) The information provided on this form is true, complete and accurate.

b) The business is not engaged in, nor will it engage in, practices involving bribery, kickbacks, or corrupt payments in connection with performance.

c) Ownership Status (select all that apply): Small business Minority-owned Women-owned Veteran-owned

Scope of Work

Payment Terms

Term and Termination

Effective Date:    Termination Date:

Confidentiality

The business acknowledges that in the course of performance it may receive confidential or proprietary information. The business agrees to hold confidential information in strict confidence, not to disclose to third parties, and to use such information only for performance under the applicable order or agreement. Exceptions shall be limited to information that is: (a) publicly known through no fault of the receiving party; (b) rightfully received from a third party without restriction; or (c) independently developed without use of confidential information.

The business certifies acceptance of the confidentiality obligations:

Governing Law; Entire Agreement

Governing Law: This form and any transaction that relies upon these representations and certifications shall be governed by the laws of the State of , without regard to conflict of law principles.

Entire Agreement: These representations and certifications constitute the complete and exclusive statement of the representations made by the business with respect to the matters contained herein and supersede all prior understandings and agreements, whether written or oral, relating to such matters.

Certification and Signature

The undersigned, representing and acting on behalf of the business identified above, certifies, under penalty of perjury and to the best of the signatory's knowledge, that the foregoing representations and certifications are true, correct and complete.

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