Client Info Request Form

Client Information Request and Services Agreement

Parties and Recitals

This Agreement is entered into between Client Name: ("Client") and Service Provider Name: ("Service Provider"), effective as of Effective Date: .

WHEREAS, Client seeks to retain Service Provider to perform certain professional services and requires the collection of specific client data and documentation to commence such services; and

WHEREAS, Service Provider requires accurate information from Client to evaluate, plan and execute the Scope of Work and agrees to treat such information as confidential under the terms set forth herein.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows.

Client Information (Required)

Corporation    LLC    Partnership    Individual/Sole Proprietor

Scope of Work

Service Provider shall perform the services described below. Client must provide the information requested in this form and any additional documentation reasonably required for Service Provider to perform the services.

Payment Terms

Client agrees to compensate Service Provider as follows.

Check    ACH / Bank Transfer    Credit Card    Other:

Term and Termination

The term of this Agreement commences on Start Date: and continues until End Date: unless earlier terminated in accordance with this Section.

Either party may terminate this Agreement for any reason upon written notice delivered at least Notice Period (days): days to the other party. Termination does not relieve Client of the obligation to pay for services performed and expenses incurred through the effective date of termination.

Confidentiality

"Confidential Information" means non-public information disclosed by one party to the other that is identified as confidential at the time of disclosure or by its nature would reasonably be considered confidential. Service Provider agrees to hold Confidential Information in strict confidence and not to disclose it except to employees, contractors or agents who need to know and who are bound by confidentiality obligations no less protective than those herein. Confidential Information does not include information that (a) is or becomes public through no fault of the receiving party, (b) was rightfully known to the receiving party prior to disclosure, (c) was disclosed by a third party without restriction, or (d) is independently developed by the receiving party without use of the disclosing party's Confidential Information.

The obligations of confidentiality survive termination of this Agreement for a period of three (3) years, except for trade secrets where protection shall continue for the period provided by law.

Use of Client Information and Documentation

Client authorizes Service Provider to collect, store and use the information provided in this form solely for purposes of performing the Scope of Work, billing, and compliance with legal obligations. Service Provider will retain records in accordance with its record retention policy and applicable law.

Representations and Warranties

Client represents that the information supplied is true, complete and accurate to the best of Client's knowledge. Client will promptly notify Service Provider of any material changes to the information provided.

Governing Law; Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the State of: without regard to its conflicts of law principles. Any dispute arising under this Agreement will be resolved by binding arbitration if both parties agree in writing; otherwise, disputes shall be resolved in the courts located in the designated state.

Entire Agreement; Amendments

This Agreement, including any attachments and the information provided by Client in this form, constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. Any amendment or modification to this Agreement must be in writing and signed by authorized representatives of both parties.

Certifications and Required Attachments

By signing below, Client certifies that the information provided is accurate and that Client has authority to provide the information and to enter into this Agreement. Client must provide copies of the following documents as applicable (check all attached):

W-9 or applicable tax form    Certificate of Insurance    Operating Agreement / Articles of Organization    Other Documents:

Additional Notes

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