Client Data Collection Questionnaire

CLIENT DATA COLLECTION QUESTIONNAIRE

Recitals

THIS QUESTIONNAIRE is entered into between Client Name: and Service Provider: (collectively the Parties), effective as of Effective Date: .

WHEREAS, the Client seeks to engage the Service Provider to collect, process and maintain certain client data in connection with the services described herein; and WHEREAS, the Service Provider will collect, maintain and use such data in accordance with the terms, security measures and confidentiality obligations set forth in this Questionnaire and any governing agreement between the Parties.

Party Information

Corporation    LLC    Individual    Other:

Scope of Work

Describe the services and data collection activities the Service Provider will perform. Include frequency, deliverables and any exclusions.

Data Collection Details

Indicate the categories of data to be collected, processed or stored by the Service Provider.

Personal Identifiable Information (name, DOB, SSN)
Financial Information (bank, account, payment history)
Health Information (medical records)
Employment Records (salary, performance)
Confidential Business Information (trade secrets, strategies)
Other:

Retention, Storage, and Security

Minimum security measures to be applied (check all that apply):

Encryption at rest and in transit
Role-based access controls and authentication
Logging and audit trails
Physical security controls for on-site storage
Incident detection and response procedures

Payment Terms

Compensation for the Service Provider's data collection services shall be as follows.

Term and Termination

This Questionnaire commences on Start Date: and continues until End Date: unless earlier terminated in accordance with this section.

Either Party may terminate for convenience upon Notice Period (days): days' written notice. Termination for cause is permitted where a material breach is not cured within Thirty (30) days after written notice of breach.

Confidentiality

The Parties acknowledge that collected data and all information designated as confidential constitute Confidential Information. The Service Provider shall (a) use Confidential Information solely for the purposes described in this Questionnaire; (b) restrict access to Confidential Information to personnel with a need to know; (c) implement and maintain reasonable administrative, technical and physical safeguards to protect Confidential Information; and (d) not disclose Confidential Information except as required by law or with the Client's prior written consent. Upon termination, the Service Provider shall return or securely delete Confidential Information in accordance with the agreed retention policy unless legally required to retain.

Compliance and Certifications

By signing below, the Client represents and warrants that it has the authority to provide the data described herein and that collection and processing by the Service Provider as described will be lawful and in compliance with applicable data protection laws. The Service Provider represents that it will process data in accordance with applicable law and the security commitments set out in this Questionnaire.

Governing Law; Entire Agreement

This Questionnaire shall be governed by the laws of the State of: , without regard to conflict of laws principles. This Questionnaire, together with any referenced master services agreement executed by the Parties, constitutes the entire understanding between the Parties concerning the subject matter hereof and supersedes all prior proposals and communications, whether oral or written.

Miscellaneous Provisions

Amendments must be in writing and signed by authorized representatives of both Parties. Neither Party may assign its rights or obligations under this Questionnaire without the other's prior written consent, except that the Service Provider may assign to an affiliate or in connection with a merger or sale of substantially all assets.

Acknowledgment and Accuracy

The undersigned certify that the information provided in this Questionnaire is true, complete and accurate to the best of their knowledge and that they are authorized to provide such information on behalf of their respective Parties.

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