Customer Verification Form

CUSTOMER VERIFICATION FORM

Effective Date:

RECITALS

WHEREAS, Company Name: provides customer onboarding, identity verification, and compliance services; and

WHEREAS, Customer Name: seeks to be verified for the purposes described herein; and

WHEREAS, Account Number: will be used to associate verification records with the Customer.

CUSTOMER INFORMATION

IDENTIFICATION

Select identification provided:

VERIFICATION CHECKLIST

The verifier affirms that the following steps were completed and documents were retained as indicated.

SCOPE OF WORK

The Company shall perform identity and risk verification services for the Customer limited to the tasks described below. Any work beyond this scope requires a separate written agreement.

PAYMENT TERMS

Customer shall pay the Company the agreed verification fee as set forth below. All fees are due when invoiced unless otherwise stated.

Late payments shall accrue interest at the rate of on the outstanding balance, plus any costs of collection, including reasonable attorney fees.

TERM AND TERMINATION

This verification engagement commences on Start Date: and continues until End Date: unless earlier terminated as provided below.

Either party may terminate for convenience upon written notice delivered not less than days prior to termination. Termination for cause may be immediate if the non-breaching party provides written notice describing the breach and the breach remains uncured.

Termination does not relieve the Customer of payment obligations for services rendered or costs incurred prior to the effective date of termination.

CONFIDENTIALITY

Each party shall keep confidential all non-public information obtained from the other party in connection with this verification engagement. Confidential information excludes information that is (a) publicly available without breach of this Agreement, (b) rightfully received from a third party free of obligation of confidentiality, or (c) independently developed without use of the disclosing party’s confidential information.

The receiving party shall use no less than reasonable care to protect confidential information and shall restrict access to employees and agents with a need to know. Disclosure required by law or regulation is permitted only after prompt notice to the disclosing party and to the extent allowed by applicable law.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of: , without regard to conflicts of law principles.

ENTIRE AGREEMENT

This document, together with any attachments and express written amendments signed by both parties, constitutes the entire agreement between the parties with respect to customer verification services and supersedes all prior negotiations, representations and agreements, whether written or oral. Modifications must be in writing and signed by authorized representatives of both parties.

CUSTOMER DECLARATION AND CONSENT

I certify under penalty of law that the information provided on this form is true, complete, and accurate to the best of my knowledge. I authorize the Company to collect, verify, retain, and share identity-related information and documentation with third parties as reasonably required to complete verification and to comply with applicable laws and regulations.

REPRESENTATIONS AND WARRANTIES; LIMITATION OF LIABILITY

Each party represents that it has the authority to enter into this Agreement. The Company warrants that verification services will be performed in a commercially reasonable manner. Except for willful misconduct or gross negligence, the Company's liability for any claim arising out of or related to this Agreement shall not exceed the fees paid by the Customer for the verification services giving rise to the claim.

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