Institutional Client Intake Form

Institutional Client Intake Form

Parties and Recitals

This Intake Form and Engagement Terms (the "Agreement") is made between Institution Name: and Service Provider Name: .

WHEREAS, Institution seeks to retain Provider to perform professional services described herein; and

WHEREAS, Provider represents that it has the requisite experience, qualifications, and resources to provide the requested services in accordance with the terms of this Agreement; and

WHEREAS, the parties agree to document institutional intake information and to set forth the principal commercial and legal terms governing the services to be performed.

Institution Details

Non-profit Government Private Educational Other:

Scope of Work

Describe the services, deliverables, milestones, and acceptance criteria. Include any institutional requirements and special handling instructions.

Payment Terms

The Institution shall pay Provider in accordance with the following terms. Invoices will be issued in accordance with the schedule below and are payable in U.S. dollars unless otherwise agreed in writing.

All invoices must include a purchase order number where required by Institution procurement policy. Taxes and other governmental charges shall be the responsibility of the party required to pay them under applicable law.

Term and Termination

This Agreement commences on Start Date: and continues until End Date: unless earlier terminated in accordance with this Section.

Either party may terminate for convenience upon providing Notice Period: days' prior written notice. Termination for material breach is effective upon written notice if the breaching party does not cure within thirty (30) days of receipt of notice unless otherwise specified in writing.

Confidentiality

Each party shall maintain the confidentiality of Non-Public Information disclosed by the other party in connection with this Agreement. Confidential Information does not include information that is (a) publicly available through no breach of this Agreement, (b) independently developed by receiving party without use of disclosing party's Confidential Information, or (c) rightfully received from a third party without restriction. The parties agree to use Confidential Information solely for performance of this Agreement and to apply commercially reasonable safeguards to prevent unauthorized disclosure.

Compliance and Certifications

By completing this Intake Form, Institution certifies that it will comply with applicable export, privacy, and data protection laws in its use of services provided by Provider.

Data Handling Requirements (check all that apply):

Personal Identifiable Information (PII) Protected Health Information (PHI) Restricted/Sensitive Data

Yes No

Governing Law and Entire Agreement

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. Any dispute arising under or related to this Agreement shall be subject to the exclusive jurisdiction of the state and federal courts located in that state, unless the parties agree in writing otherwise.

This document, together with any referenced attachments and accepted purchase orders, constitutes the entire agreement between the parties concerning its subject matter and supersedes all prior negotiations, representations, and agreements, whether written or oral. No modification or waiver shall be effective unless in writing and signed by an authorized representative of each party.

Attachments and Additional Information

Acknowledgment

By signing below, each party represents and warrants that the information provided in this Intake Form is accurate and complete to the best of its knowledge; that it has the authority to enter into this Agreement on behalf of the party identified; and that it agrees to the terms set forth herein.

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