Legal Applicant Statement

LEGAL APPLICANT STATEMENT

This Legal Applicant Statement (the Statement) is made and entered into by and between Applicant Name: and Recipient Name: , effective as of Effective Date: .

RECITALS

WHEREAS, Applicant has completed or will complete an application, questionnaire, or other forms and seeks consideration by Recipient for the purpose described herein; and

WHEREAS, Recipient requires certain attestations, authorizations, and releases from Applicant as a condition of evaluation and to verify information supplied by Applicant; and

WHEREAS, the parties desire to set forth their respective representations, authorizations, and the terms upon which Recipient may collect, use, retain, and disclose Applicant information.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Statement, the following terms shall have the meanings set forth below: "Applicant" means the natural person identified above; "Recipient" means the entity identified above; "Information" means any written, electronic, or oral data, records, reports, or other materials concerning Applicant, including but not limited to application materials, employment history, education, criminal history, and identity verification records.

2. APPLICANT REPRESENTATIONS AND WARRANTIES

Applicant represents and warrants that all Information submitted to Recipient is true, complete, and correct to the best of Applicant's knowledge. Applicant acknowledges that Recipient may rely upon such Information in determining Applicant's suitability and that any material misrepresentation or omission shall constitute grounds for denial of the application or termination of any relationship resulting from the application.

3. AUTHORIZATION AND RELEASE

Applicant authorizes Recipient and its agents, contractors, service providers, and authorized representatives to obtain, collect, and review Information about Applicant from third-party sources, including consumer reporting agencies, employers, educational institutions, licensing authorities, and law enforcement agencies, as permitted by applicable law. Applicant hereby releases and holds harmless Recipient and each such third party from any liability arising from the collection, maintenance, disclosure, or use of such Information in accordance with this Statement.

4. BACKGROUND CHECKS; CONSENT

Applicant consents to the following checks and authorizations as applicable to the Recipient's evaluation process (check to indicate consent):

Criminal history check

Employment verification

Education verification

Identity verification

5. APPLICANT INFORMATION

6. DISCLOSURES AND EXPLANATIONS

Yes No

7. USE, RETENTION, AND CONFIDENTIALITY

Recipient may use Information for purposes of evaluation, compliance, and recordkeeping. Recipient will retain Information for such period as reasonably necessary in light of the purpose for which the Information was collected and as required by law. Recipient will treat Information as confidential and will not disclose Information to third parties except to those agents, contractors, or authorities with a legitimate need to know or as required by law. Notwithstanding the foregoing, Applicant acknowledges that certain Information may be retained in Recipient's records or in third-party archives even if no further action is taken on the application.

8. ACCURACY, CERTIFICATION, AND PENALTIES

Applicant certifies under penalty of perjury that the Information provided in connection with this Statement and any accompanying application is true, complete, and correct. Applicant understands that knowingly making a false statement or omission may subject Applicant to civil or criminal penalties and may disqualify Applicant from consideration or result in termination of any subsequent engagement.

9. INDEMNIFICATION

Applicant agrees to indemnify and hold harmless Recipient, its officers, directors, employees, agents, and contractors from and against any and all claims, liabilities, losses, costs, and expenses (including reasonable attorneys' fees) arising out of Applicant's breach of this Statement, willful misrepresentation, or negligent provision of Information.

10. NOTICES

All notices required or permitted under this Statement shall be in writing and shall be deemed delivered when delivered in person, sent by certified mail, return receipt requested, or by nationally recognized overnight courier, to the address set forth below for each party.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Statement shall be governed by and construed in accordance with the laws of the jurisdiction where Recipient maintains its principal place of business, without regard to conflict of law principles. This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, and negotiations, whether written or oral. If any provision of this Statement is held to be invalid or unenforceable, such invalidity or unenforceability shall not affect the remaining provisions, which shall remain in full force and effect.

12. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment or modification of this Statement shall be effective unless in writing and signed by both parties. No waiver of any breach or default shall be deemed a waiver of any subsequent breach or default. This Statement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

13. ACKNOWLEDGMENT

Applicant acknowledges receipt of a copy of this Statement and understands that Applicant may be asked to provide additional documentation to verify the Information provided. Applicant further acknowledges that submission of Information does not guarantee selection, engagement, or employment and that Recipient's decision may be based on the results of verifications and assessments.

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