Legal Certificate Application

LEGAL CERTIFICATE APPLICATION

This Legal Certificate Application is submitted on behalf of Applicant Name: , Entity Type: Individual Corporation LLC Partnership Other , Registered Jurisdiction: , Registration/ID Number: . Application Date:

RECITALS

WHEREAS, Applicant seeks issuance of a legal certificate by Issuing Authority for the purpose stated herein and in reliance on the representations and supporting documentation provided; and

WHEREAS, Issuing Authority is authorized under applicable law and its governing rules to review, verify, and issue such certificates upon satisfactory demonstration of facts and payment of applicable fees; and

WHEREAS, the parties desire to set forth the terms and conditions under which Issuing Authority will consider and, if appropriate, issue the requested certificate.

NOW, THEREFORE, in consideration of the mutual covenants contained in this Application and for other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as set forth below.

1. APPLICATION REQUEST

Applicant requests issuance of the following certificate(s) (select all that apply): Certificate of Good Standing Certificate of Incumbency Certificate of Authorization/Power Certified Copy of Record Other

2. SUPPORTING DOCUMENTATION

Applicant certifies that the following documentary evidence accompanies this Application (select all that apply): Articles of Incorporation / Organization By-Laws / Operating Agreement Corporate/Member Resolution authorizing request Valid government-issued identification for signatory Power of Attorney or other authority documentation

3. FEES AND PAYMENT

Applicant shall pay the fee required for processing and issuance: Fee Amount: . Payment Method: Check Wire / Electronic Card Reference / Transaction ID:

4. REPRESENTATIONS, WARRANTIES AND AUTHORIZATIONS

Applicant represents and warrants to Issuing Authority that: (a) all information and documents submitted in support of this Application are true, complete and accurate; (b) Applicant is duly formed and in good standing (if applicable) in the jurisdiction identified above; (c) the person signing this Application is authorized to make these representations and to request issuance of the certificate on Applicant's behalf; and (d) issuance of the certificate will not violate any law, agreement or obligation to which Applicant is subject.

Applicant authorizes Issuing Authority to verify the facts and documentation presented, to obtain additional information as reasonably necessary, and to rely upon the representations herein in determining whether to issue the requested certificate.

5. INDEMNIFICATION

Applicant shall indemnify, defend and hold harmless Issuing Authority and its officers, employees and agents from and against any and all claims, liabilities, losses, costs and expenses (including reasonable attorneys' fees) arising out of or in connection with the Application, any inaccuracy in the representations or documents provided, and Issuing Authority's reliance on such representations in issuing or refusing to issue the certificate.

6. NOTICES

All notices required or permitted under this Application shall be in writing and shall be delivered by hand, certified mail (return receipt requested), or commercial courier to the addresses set forth above, and shall be effective upon receipt.

7. MISCELLANEOUS PROVISIONS

Governing Law: This Application and any certificate issued pursuant hereto shall be governed by and construed in accordance with the laws of the jurisdiction of Registered Jurisdiction identified above, without regard to its conflict of law principles.

Entire Agreement: This Application constitutes the entire agreement between Applicant and Issuing Authority with respect to the subject matter hereof and supersedes all prior negotiations, communications and understandings, whether written or oral.

Severability: If any provision of this Application is determined to be invalid or unenforceable, such determination shall not affect the validity or enforceability of any other provision, which shall remain in full force and effect.

Amendments and Waiver: No amendment or waiver of any provision of this Application will be effective unless made in a written instrument signed by both Applicant and an authorized representative of Issuing Authority.

Counterparts: This Application may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Facsimile or electronic signatures shall be treated as original signatures for all purposes.

8. CERTIFICATION

The undersigned certifies, under penalty of perjury, that the foregoing statements made by the Applicant are true and correct, that the signatory is authorized to execute this Application on behalf of the Applicant, and that the Applicant understands and agrees to the terms, representations and indemnities set forth in this Application.

SIGNATURES

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