Data Collection Application

Data Collection Application and Agreement

Application Number:

RECITALS

WHEREAS, Provider Name: is authorized to facilitate the collection, storage and limited disclosure of data pursuant to the terms set forth herein; and

WHEREAS, Applicant Name: seeks authorization to collect specified categories of data for the project described in this application and agrees to comply with the conditions in this Agreement; and

WHEREAS, both parties desire to set forth the scope, security, payment and legal terms under which such data collection will occur.

APPLICANT INFORMATION

PROJECT DETAILS AND SCOPE

DATA CATEGORIES AND COLLECTION METHODS

Select data categories proposed for collection (check all that apply):

DATA RETENTION, SECURITY, AND COMPLIANCE

The Applicant certifies that all data collection and handling activities described herein will comply with applicable privacy, data protection and sector-specific legal obligations. Applicant agrees to obtain any necessary consents and to maintain records evidencing lawful collection.

PAYMENT TERMS

Applicant agrees to pay Provider the fees set forth below in consideration for services, approvals, and oversight associated with the data collection activities.

TERM AND TERMINATION

This Agreement commences on the Effective Date below and continues until the earlier of completion of the Scope of Work or the Expiration Date below, unless earlier terminated in accordance with this section.

Either party may terminate this Agreement for material breach by the other party if the breaching party fails to cure such breach within days after written notice. Provider may suspend data collection activities immediately if, in Provider's reasonable judgment, continuation would create material legal, security, or privacy risk.

CONFIDENTIALITY

Each party shall treat non-public information received from the other party as Confidential Information and shall not disclose such information except to its employees, contractors or agents who have a need to know and who are bound by confidentiality obligations at least as protective as those herein. Confidential Information shall not include information that is (a) publicly available through no fault of the recipient, (b) already lawfully known by the recipient, (c) independently developed by the recipient without use of the disclosing party’s Confidential Information, or (d) required to be disclosed by law, provided the recipient provides prompt notice and cooperates with reasonable steps to limit disclosure.

GOVERNING LAW

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. Exclusive venue for any dispute arising under this Agreement shall be the state or federal courts located within that State.

ENTIRE AGREEMENT

This Agreement, together with any schedules or attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior or contemporaneous agreements, understandings, negotiations and communications, whether written or oral. No modification shall be effective unless in writing and signed by an authorized representative of both parties.

CERTIFICATIONS AND ACKNOWLEDGMENTS

By submitting this application, Applicant certifies that the information provided is true and accurate to the best of Applicant’s knowledge, that Applicant has obtained any necessary consents for data collection and processing, and that Applicant will implement and maintain the security measures described above. Applicant acknowledges that material misrepresentation or failure to comply with this Agreement may result in revocation of authorization and other remedies.

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