Identification Certificate

IDENTIFICATION CERTIFICATE

Certificate No.:   Date of Issuance:

RECITALS

WHEREAS, Issuer Name: (hereinafter "Issuer") is authorized to verify and certify personal identification for the purposes set forth herein; and

WHEREAS, Subject Name: (hereinafter "Subject") has presented satisfactory documentary and physical evidence of identity to the Issuer; and

WHEREAS, the parties desire to set forth the terms under which the Issuer certifies the identity of the Subject for reliance by third parties where appropriate and lawful.

IDENTIFIED PERSON — DETAILS

IDENTIFICATION DOCUMENT(S) PRESENTED

The following original or certified documents were presented and examined by the Issuer:

Passport    Driver's License    National ID Card    Other    Description:

Issue Date:    Expiry Date:

PHYSICAL DESCRIPTION

Height:    Weight:    Eye Color:

CERTIFICATION

I, , acting in the capacity of for Issuer Name: , do hereby certify under penalty of law that on the date of issuance stated above I examined the identification documents and the identity of Subject Name: and that, to the best of my knowledge and belief, the person identified therein is the same person who appeared before me.

The Issuer affirms that the procedures employed to verify identity were reasonable and consistent with the Issuer's policies. This Certificate is issued solely for the purpose(s) described in the Scope of Identification section below and for reliance by third parties only to the extent permitted by law.

SCOPE OF IDENTIFICATION

PAYMENT TERMS (IF APPLICABLE)

Administrative Fee:    Payment Schedule:

Late Fee: (applies to outstanding administrative charges where permitted by law).

TERM AND TERMINATION

Effective Date:    Expiration Date (if any):

This Certificate remains valid for the period specified above or, if no expiration date is specified, until revoked in writing by the Issuer. Revocation or termination of this Certificate shall be effective upon written notice delivered to the other party. Required notice period (days):

CONFIDENTIALITY

The Issuer shall maintain reasonable administrative, technical, and physical safeguards to protect personal information collected in connection with this Certification. The Issuer will not disclose Subject's personal data except (a) as required by law or court order, (b) with the Subject's express written consent, or (c) to third parties who reasonably rely on this Certificate for lawful purposes and whose receipt of such information is necessary for that purpose. Any permitted disclosure shall be limited to the minimum information necessary.

GOVERNING LAW

This Certificate shall be governed by and construed in accordance with the laws of the jurisdiction of: , without regard to conflict of laws principles.

ENTIRE AGREEMENT

This Certificate, together with any attachments or exhibits expressly incorporated herein, constitutes the entire agreement between the Issuer and the Subject with respect to the certification of identity and supersedes all prior or contemporaneous understandings, representations, warranties and agreements, written or oral, regarding the subject matter hereof.

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