Client Self-Authorization Form

CLIENT SELF-AUTHORIZATION FORM

Client Identification

Recitals

WHEREAS, Client Name: seeks to authorize the Service Provider to act on Client's behalf for the limited purposes described in this authorization;

WHEREAS, the Service Provider requires written authorization from the client to access accounts, obtain information, and take designated actions; and

WHEREAS, the parties desire to record the scope, limitations, term, and conditions of the authorization and related payment obligations as set forth below.

Scope of Authorization and Scope of Work

Client hereby authorizes Service Provider to perform the following actions on Client's behalf. The specific services, limits, and identifiers must be set forth below. Actions not expressly listed remain outside the scope of this authorization.

Authorization Specifics

Client expressly authorizes the following (check all that apply):

Payment Terms

In consideration for the services provided under this authorization, Client agrees to the following payment terms:

Term and Termination

This authorization commences on and continues until , unless earlier revoked or terminated pursuant to this section.

Either party may terminate this authorization upon written notice to the other party. Notice of termination must be provided at least days prior to the termination effective date, except where immediate termination is permitted for material breach.

Confidentiality

Service Provider shall maintain in strict confidence all non-public information obtained from Client in connection with this authorization and shall not disclose such information except to perform the authorized services, to comply with law, or with Client's prior written consent. Service Provider shall use at least the same degree of care to protect Client information as it uses to protect its own confidential information, but in no event less than reasonable care.

Representations; Limitation of Authority; Indemnity

Client represents and warrants that Client has full authority to grant the authorizations in this form and that the execution of this authorization does not violate any agreement or law. Service Provider's authority is limited to those actions expressly described in the Scope of Work. Client agrees to indemnify and hold Service Provider harmless from claims, liabilities, losses, or expenses arising from Client's false representations, Client-directed actions outside the scope, or Client's breach of this authorization, except to the extent caused by Service Provider's gross negligence or willful misconduct.

Revocation

Client may revoke this authorization at any time by providing written notice to Service Provider. Revocation becomes effective upon Service Provider's receipt of such written notice, except to the extent that Service Provider has already acted in reliance on this authorization. Notices of revocation must be sent to the Service Provider contact listed below.

Governing Law; Dispute Resolution

This authorization shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws rules. Any dispute arising out of or relating to this authorization shall be resolved in the state or federal courts located in that state, and each party consents to exclusive jurisdiction and venue therein.

Entire Agreement

This document, together with any attachments and the Scope of Work, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. Any amendment or modification must be in writing and signed by both parties.

Client Certifications

By signing below, Client certifies that the information provided in this form is true and accurate, that Client has the authority to grant the authorizations herein, and that Client understands the scope and limitations of the Service Provider's authority.

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