E-Signature Consent Form

E-SIGNATURE CONSENT FORM

Client Name:   Provider Name:

WHEREAS

WHEREAS, Client desires to receive and execute certain agreements, disclosures, invoices, statements and related documents electronically rather than in paper form; and

WHEREAS, Provider is willing to permit electronic delivery and electronic execution of such documents subject to the terms and conditions set forth in this Consent Form; and

WHEREAS, the parties intend that electronic records and electronic signatures shall have the same force and effect as paper records and handwritten signatures, to the extent permitted by applicable law.

SCOPE OF DOCUMENTS

ELECTRONIC CONSENT

By checking the consent box below and signing this form, Client expressly consents to the use of electronic records and electronic signatures for the documents described in Scope of Documents. Client acknowledges that electronic signatures executed in accordance with the methods described herein constitute valid and binding signatures.

I consent to receive, review, sign and transmit documents electronically.

ELECTRONIC NOTICES AND CONTACT

Client agrees that electronic delivery of notices and documents to the email address provided above satisfies any legal requirement that such communications be in writing.

HARDWARE AND SOFTWARE REQUIREMENTS

Client represents that Client has the necessary hardware, software and internet access to receive, open, view and retain electronic documents in the format provided. Typical requirements may include a modern web browser and a PDF reader.

I acknowledge that I have the required hardware and software to access and retain electronic documents.

WITHDRAWAL OF CONSENT

Client may withdraw consent to receive documents electronically by giving written notice to Provider at the contact address or primary email set forth above. Withdrawal of consent will be effective only after Provider has a reasonable period to process the request. Withdrawal of consent will not affect the legal validity or enforceability of any electronic document previously executed.

RETENTION OF RECORDS

Provider will retain copies of electronic records in a form that is capable of being accurately reproduced for later reference. Client may request a paper copy of any electronically delivered document; Provider may charge a reasonable fee to cover the cost of reproduction.

PAYMENT TERMS

Client authorizes Provider to deliver invoices and billing statements electronically and to accept electronic payment authorization consistent with the Payment Terms set forth above.

TERM AND TERMINATION

This Consent Form is effective as of Start Date: and continues until End Date: , unless earlier terminated in accordance with this section.

Termination of this Consent Form will not affect the validity or enforceability of electronic documents executed prior to termination.

CONFIDENTIALITY

Both parties shall maintain the confidentiality of all nonpublic information contained in electronic records to the same extent as required for paper records, and shall implement reasonable administrative, technical and physical safeguards to protect such information from unauthorized access or disclosure.

GOVERNING LAW

This Consent Form shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts of law rules.

ENTIRE AGREEMENT

This Consent Form, together with any documents incorporated by reference and any agreements referenced herein, constitutes the entire agreement between Client and Provider concerning the subject matter of this Consent Form and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

MISCELLANEOUS PROVISIONS

If any provision of this Consent Form is held invalid or unenforceable, the remainder shall remain in full force and effect. Headings are for convenience only and shall not affect interpretation.

ACKNOWLEDGMENT

By signing below, Client certifies that Client has read, understands and agrees to the terms of this Consent Form and that Client's electronic signature is the legal equivalent of Client's handwritten signature.

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