Legal Conviction Document

Legal Conviction Document

This Legal Conviction Document (the "Document") is made and entered into as of Effective Date: by and between Declarant Name: with principal address: and Recipient Name: with principal address: . Each of the foregoing is a "Party" and collectively the "Parties."

RECITALS

WHEREAS, Declarant acknowledges that Declarant has been convicted of one or more criminal offenses and the disclosure of those convictions is material to Recipient in connection with Recipient's consideration of Declarant for licensing, employment, contracting, certification, or similar regulatory matters;

WHEREAS, Recipient requires an accurate, complete and continuing disclosure of Declarant's convictions to evaluate risk, compliance and suitability, and will rely upon the representations and certifications set forth in this Document; and

WHEREAS, Declarant desires to make a full written disclosure to Recipient and to certify the truthfulness of such disclosure under penalty of law as provided herein.

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

1. DEFINITIONS

For the purposes of this Document the following definitions apply:

"Conviction" means a final judgment of guilt entered by a court of competent jurisdiction following a plea, verdict, or other determination of guilt for a criminal offense.

"Disclosure" means the written account of each Conviction provided by Declarant under Section 2 of this Document.

2. DISCLOSURE OF CONVICTIONS

Declarant hereby discloses the following convictions. Declarant certifies that the information set forth below is complete and accurate to the best of Declarant's knowledge. If any cell is not applicable, enter "N/A."

Conviction 1

Felony Misdemeanor Infraction

Conviction 2 (if any)

Felony Misdemeanor Infraction

3. ADDITIONAL CONVICTIONS

4. CERTIFICATION AND ATTESTATION

Declarant affirms and certifies, under penalty of perjury, that the information contained in this Document is true, complete and correct. Declarant acknowledges that knowingly making a false statement or omission in this Document may subject Declarant to criminal or civil penalties under applicable law.

Declarant hereby authorizes Recipient and its agents to obtain, inspect and verify any records, court dispositions, case files, probation records, and other official documents relevant to the disclosed convictions. Such authorization is limited to information relevant to the convictions disclosed and does not constitute an unlimited waiver of privacy.

5. DUTY TO UPDATE

Declarant agrees to notify Recipient in writing of any new conviction or material change in the status of any disclosed conviction within Notification Period (days): calendar days of the final determination or change. Failure to timely update may constitute a material breach of this Document.

6. RECIPIENT RIGHTS AND REMEDIES

Recipient shall have the right to rely on Declarant's disclosures in making decisions regarding employment, licensing, contracting, or other regulated relationships. In the event of a material misrepresentation or omission, Recipient may take any lawful action, including disciplinary action, revocation of license or offer, termination of contract or employment, or seeking damages.

7. CONFIDENTIALITY AND USE OF INFORMATION

Recipient agrees to treat Declarant's Disclosure as confidential information and to use the information solely for the purposes described in this Document, compliance, or as required by law. Recipient may disclose Disclosure to its legal counsel, auditors or regulators on a need-to-know basis. Recipient's retention period for records relating to this Disclosure (years):

8. NOTICES

All notices, requests, consents and other communications required or permitted under this Document shall be in writing and sent to the addresses set forth below. Receipt by hand, certified mail, or delivery service shall constitute effective notice.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Document shall be governed by and construed in accordance with the laws of State of Governing Law: without regard to principles of conflicts of law. This Document constitutes the entire agreement between the Parties relating to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings of the Parties. If any provision of this Document is held to be invalid or unenforceable, that provision shall be struck and the remaining provisions shall remain in full force and effect.

10. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or modification of this Document shall be effective unless in writing and signed by both Parties. No waiver of any provision hereof shall be effective unless in writing and signed by the Party granting such waiver. This Document may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument.

11. MISCELLANEOUS

The headings in this Document are for convenience of reference only and shall not affect the interpretation of this Document. The Parties acknowledge that each has had the opportunity to seek independent legal advice prior to executing this Document.

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