Legal Application for License

LEGAL APPLICATION FOR LICENSE

This Application for License (the Application) is submitted on Date: by Applicant Name: to Licensing Authority Name: .

RECITALS

WHEREAS, Applicant conducts or intends to conduct the business described herein and seeks a license authorizing the activities and scope set forth in this Application; and

WHEREAS, Licensing Authority is empowered to grant, condition, suspend and revoke licenses of the type requested in accordance with applicable law, regulation and administrative rule; and

WHEREAS, the parties desire to set forth the information, certifications and commitments necessary to consider issuance of the requested license.

NOW THEREFORE, Applicant submits this Application and certifies the accuracy of the information provided below and agrees to be bound by the terms and conditions set forth in this Application if a license is issued.

1. DEFINITIONS

For purposes of this Application, "Applicant" means the person or entity identified as Applicant Name; "Licensing Authority" means the entity identified as Licensing Authority Name; "License" means any authorization, permit or certificate issued pursuant to this Application. Other defined terms used in this Application shall have the common and ordinary meaning unless otherwise specified herein.

2. APPLICATION INFORMATION

Individual    Corporation    LLC    Partnership    Other:

3. LICENSE REQUESTED AND SCOPE

License Type Requested: General License    Special License    Temporary License

Proposed Effective Date:    Proposed Expiration Date (if applicable):

4. FEES AND PAYMENT

Applicant acknowledges that issuance of a license may be conditioned upon payment of fees and completion of required documentation. Applicant submits the following fee payment information:

5. REPRESENTATIONS AND WARRANTIES

Applicant represents and warrants that all information submitted in this Application is true, complete and accurate to the best of Applicant's knowledge; Applicant has the authority to submit this Application and to bind the Applicant to obligations herein; Applicant has not been convicted of any offense or subject to any administrative action that would, under applicable law, disqualify Applicant from receiving the requested License, except as disclosed in the space below.

6. COMPLIANCE, RECORDS AND REPORTING

Applicant agrees to comply with all applicable statutes, regulations and conditions of any License issued, including but not limited to recordkeeping, reporting, and permitting requirements. Applicant shall maintain complete and accurate records relating to licensed activities for at least the period required by applicable law and shall provide such records to Licensing Authority upon request.

7. INSPECTION, AUDIT AND ENFORCEMENT

Licensing Authority, or its authorized agents, shall have the right to enter Applicant's premises during normal business hours to inspect operations, records and facilities to verify compliance with the License and applicable law. Such inspections shall be conducted in a reasonable manner and Licensing Authority shall provide notice to Applicant unless exigent circumstances exist. Applicant must promptly remedy any non-compliance identified by Licensing Authority.

8. SUSPENSION, REVOCATION AND CONDITIONS

Licensing Authority may deny, suspend, condition or revoke any License issued under this Application for material misrepresentation, violation of any applicable law or condition of the License, failure to pay required fees, or failure to cure deficiencies within a reasonable period. Applicant shall be afforded any procedural rights required by law prior to final adverse action.

9. INDEMNITY AND INSURANCE

Applicant shall indemnify, defend and hold harmless Licensing Authority, its officers, employees and agents from any claims, liabilities, losses or expenses arising out of Applicant's activities under any License, except to the extent caused by Licensing Authority's gross negligence or willful misconduct. Applicant shall procure and maintain insurance with minimum coverage as required by Licensing Authority.

10. CONFIDENTIALITY

Information submitted in this Application may be subject to public disclosure under applicable law. Information that Applicant designates in writing as confidential shall be treated in accordance with applicable confidentiality rules; however, Licensing Authority shall make final determinations regarding disclosure in accordance with law and regulation.

11. NOTICES

All notices required or permitted under this Application shall be made in writing and delivered by hand, certified mail, or other reliable delivery service to the addresses below.

12. AMENDMENTS, WAIVER AND COUNTERPARTS

This Application may be amended only by mutual written agreement of Applicant and Licensing Authority. No failure or delay in exercising any right, power or privilege shall operate as a waiver. This Application may be executed in counterparts, each of which shall constitute an original.

13. GOVERNING LAW, ENTIRE AGREEMENT AND SEVERABILITY

This Application shall be governed by and construed in accordance with the laws of the State of without regard to conflict of law principles. This Application constitutes the entire agreement between Applicant and Licensing Authority with respect to the subject matter hereof and supersedes all prior representations and agreements. If any provision of this Application is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

14. CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that the information contained in this Application is true, complete and correct; Applicant understands that false statements may be grounds for denial or revocation of a License and may subject Applicant to civil or criminal penalties.

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