Criminal Record Disclosure Form

CRIMINAL RECORD DISCLOSURE FORM

This Criminal Record Disclosure Form ("Form") is entered into by and between Requesting Party: and Disclosing Individual: . The parties agree that the Disclosing Individual will disclose criminal history information as set forth herein. Execution Date:

RECITALS

WHEREAS, Requesting Party requires disclosure of certain criminal history information from Disclosing Individual for the purpose of evaluation for employment, licensing, placement, or other lawful purposes; and

WHEREAS, Disclosing Individual has knowledge of, or may have records reflecting, arrests, charges, convictions, deferred adjudications, diversions, or other dispositions that may be relevant to Requesting Party's evaluation; and

WHEREAS, the parties desire to set forth the terms, scope, representation, and use of any criminal record information disclosed hereunder.

NOW, THEREFORE

In consideration of the mutual promises contained herein and other good and valuable consideration, the receipt and adequacy of which are acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form: "Criminal History Information" means records or information relating to arrests, charges, indictments, convictions, deferred adjudications, diversions, probation, parole, sentencing, and records of juvenile adjudication to the extent permitted by law. "Disposition" means the final outcome or status of an arrest or charge.

2. DISCLOSURE OF CRIMINAL HISTORY

Disclosing Individual hereby affirms the following (check the applicable box and provide complete details where required):

No criminal history to disclose.

If any offenses are disclosed below, provide full factual details, dates, jurisdictions, and dispositions. Attach additional sheets if necessary.

If additional offenses exist, check here and attach separate sheets:

3. AUTHORIZATION TO OBTAIN RECORDS

Disclosing Individual authorizes Requesting Party and its authorized agents to obtain and review criminal history records, court dispositions, and related documents from law enforcement agencies, courts, and other record custodians. This authorization is limited to records reasonably related to the purpose stated in this Form.

4. REPRESENTATIONS AND WARRANTIES

Disclosing Individual certifies under penalty of perjury that all information provided in this Form and any attachments is true, complete, and accurate to the best of the individual's knowledge. Disclosing Individual acknowledges that failure to disclose material information or providing false information may constitute grounds for rejection, termination of relationship, or other lawful action.

5. USE, RETENTION, AND CONFIDENTIALITY

Requesting Party agrees to use disclosed information solely for the purpose identified in this Form and to retain such information only as necessary and consistent with applicable law. Requesting Party will protect the confidentiality of records in its possession and will not disclose such information except as required by law or with the express written consent of Disclosing Individual.

6. NOTICE OF RIGHTS

Disclosing Individual has the right to dispute the accuracy of any records obtained and to provide explanatory information or documentation. Requesting Party will provide Disclosing Individual with notice and an opportunity to review any adverse determination based on the disclosed information, where required by applicable law or policy.

7. REMEDIES

Each party's remedies for breach of this Form shall include any equitable or legal relief available under law, including injunctive relief and recovery of costs and attorneys' fees where permitted. Nothing in this Form limits statutory rights afforded to Disclosing Individual.

8. NOTICES

Notices required under this Form shall be in writing and delivered to the addresses below by hand, certified mail, or other documented delivery method.

9. AMENDMENTS, WAIVER, COUNTERPARTS

This Form may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party waiving compliance. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

10. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Form shall be governed by the laws of the state indicated by Requesting Party's principal address without regard to conflict of law principles. If any provision of this Form is held invalid or unenforceable, the remainder shall remain in full force and effect. This Form constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior understandings and agreements, whether written or oral.

11. ATTESTATION AND CONSENT

By signing below, Disclosing Individual attests under penalty of perjury that the information provided is true and complete. Disclosing Individual further consents to the release and use of criminal history information as described in this Form and authorizes Requesting Party to contact agencies and institutions to verify the foregoing.

ACKNOWLEDGMENTS

Disclosing Individual acknowledges receipt of this Form, understands the scope of the authorization, and acknowledges that signature constitutes a voluntary and informed consent to the disclosures authorized herein.

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