Legal Citizens Application Form

LEGAL CITIZENS APPLICATION FORM

This Legal Citizens Application Form (this "Application") is executed on this date: Month Day Year , by and between Applicant Name: whose primary address is ("Applicant"), and Program Name: with principal address ("Program").

RECITALS

WHEREAS, Applicant seeks recognition and enrollment in the Program's Legal Citizens registry for the purpose of receiving verification, advocacy, and administrative services offered by Program; and

WHEREAS, Program administers a standardized process to evaluate applications, confirm eligibility and maintain records subject to lawful requests and disclosures; and

WHEREAS, the parties desire to set forth the terms under which Applicant submits personal information, supporting documentation, and certifications for Program's review, and the obligations of each party following enrollment.

NOW, THEREFORE, in consideration of mutual covenants and the promises contained herein, the parties agree as follows.

1. APPLICATION AND ELIGIBILITY

Applicant submits the following personal information and supporting documentation for the limited purpose of assessment of eligibility under Program standards. Applicant acknowledges that Program may verify information with third parties and governmental entities as permitted by law and as necessary to determine eligibility.

Citizen Permanent resident Other (describe below)

2. SUPPORTING DOCUMENTATION

Applicant shall provide legible copies of one or more of the following documents as evidence of identity or status. Program may request originals or certified copies for verification.

Passport Birth certificate National identity card Other supporting documents (describe below)

3. CERTIFICATIONS AND REPRESENTATIONS

Applicant certifies under penalty of perjury that all information and documentation submitted in connection with this Application are true, correct and complete to the best of Applicant's knowledge. Applicant acknowledges that knowingly making a false statement or submitting forged or fraudulent documentation may subject Applicant to civil or criminal liability.

Applicant expressly authorizes Program and its authorized agents to verify any information provided, to obtain records or corroborating information from third parties, and to retain copies of documentation in Program's records for lawful purposes, including audit, compliance and defense of claims.

Applicant agrees to promptly notify Program in writing of any material change to Applicant's information or status and understands that failure to do so may result in suspension or revocation of enrollment.

4. USE, RETENTION AND DISCLOSURE OF INFORMATION

Program shall use Applicant information solely for evaluation, enrollment, recordkeeping and activities reasonably related to Program administration. Program will retain records for a period necessary to satisfy legal, regulatory or operational requirements. Program may disclose information where required by law, court order, or to prevent fraud, or as otherwise permitted by applicable law.

5. FEES AND PAYMENT

Applicant shall pay the non-refundable application fee set by Program. Payment, when required, must accompany this Application or be submitted in the manner prescribed by Program. Failure to pay required fees may result in rejection of the Application.

6. REVIEW, APPROVAL AND NOTIFICATION

Program will review Applications in accordance with its internal procedures. Approval or denial is at the sole discretion of Program based on documented criteria. Program will provide written notice of its decision to Applicant at the contact address provided in this Application.

7. AMENDMENTS; WAIVER

Any amendment to this Application must be in writing and signed by both Applicant and an authorized representative of Program. No waiver of any provision or right under this Application shall be effective unless in writing and signed by the waiving party.

8. NOTICES

All notices required or permitted under this Application shall be in writing and delivered to the addresses provided in this Application. Notice is effective upon receipt, or if mailed, three (3) business days after posting.

9. GOVERNING LAW

This Application and any dispute arising out of or related to this Application shall be governed by and construed in accordance with the laws of the jurisdiction indicated below, without regard to its conflict of laws principles.

10. ENTIRE AGREEMENT; SEVERABILITY; COUNTERPARTS

This Application constitutes the entire agreement between Applicant and Program with respect to the subject matter herein and supersedes all prior and contemporaneous understandings and agreements, whether written or oral. If any provision of this Application is held invalid or unenforceable, such provision shall be modified to the extent necessary to make it valid and enforceable, or if modification is not possible, such provision shall be severed and the remaining provisions shall remain in full force and effect. This Application may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

11. ACKNOWLEDGMENT

By signing below, Applicant affirms that Applicant has read, understands, and agrees to the terms and conditions set forth in this Application and that the information provided is true and accurate.

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