Legal Declarations and Consents Form

LEGAL DECLARATIONS AND CONSENTS FORM

This Legal Declarations and Consents Form (the "Form") is entered into as of Effective Date: by and between: Declarant Name: with principal address and Recipient Name: with principal address .

RECITALS

WHEREAS, Declarant possesses certain personal, employment, educational and other records and information relevant to Recipient's legitimate business purposes; and

WHEREAS, Recipient requires certain consents and declarations from Declarant to permit collection, use, disclosure and retention of such information for the limited purposes described herein; and

WHEREAS, Declarant is willing to make the declarations and grant the consents specified in this Form subject to the terms and limitations set forth below.

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

1. DEFINITIONS

For purposes of this Form, the following terms shall have the meanings set forth below:

"Declarant" means the individual or entity identified as Declarant Name in the opening paragraph. "Recipient" means the party identified as Recipient Name in the opening paragraph. "Consents" means the authorizations granted by Declarant in Section 3. "Personal Information" means any information that identifies or could reasonably be used to identify Declarant.

2. DECLARATIONS

Declarant declares and warrants that Declarant has the full power, authority and legal capacity to execute this Form and to grant the Consents herein. Declarant further declares that all information provided to Recipient in connection with this Form is true, complete and correct to the best of Declarant's knowledge as of the Effective Date.

3. CONSENTS GRANTED

Declarant hereby expressly grants the following consents (check each applicable box):

  Consent to collection, use and retention of Personal Information by Recipient for the purposes of verification, evaluation and legitimate business operations, subject to the safeguards and limitations provided herein.

  Consent to conduct background checks, reference checks, employment and education verifications, and other investigations reasonably necessary for Recipient's business purposes. Declarant authorizes third-party providers to disclose such information to Recipient.

  Consent to the release of medical, employment, academic, financial or other records to Recipient or its authorized agents, as necessary and permitted by law.

  Consent to receive electronic communications and disclosures relating to the matters covered by this Form, including notices, confirmations and results, at the contact information provided in Section 8.

  Other consents: please specify in the field below.

4. SCOPE, DURATION AND REVOCATION

The Consents granted herein are limited to the purposes expressly described in this Form and shall remain effective from the Effective Date until revoked in writing. Any revocation of consent shall be effective only upon receipt by Recipient and shall not affect actions taken by Recipient prior to receipt of such revocation to the extent Recipient relied in good faith upon the previously granted consents.

5. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants that: (a) Declarant's execution of this Form does not violate any agreement or legal obligation; (b) Declarant has disclosed all material facts known to Declarant that are required for Recipient to rely upon the Consents; and (c) if Declarant executes on behalf of an entity, Declarant is authorized to bind that entity and has disclosed the signatory's title in the signature block.

6. INDEMNIFICATION

To the fullest extent permitted by law, Declarant shall indemnify, defend and hold harmless Recipient and its affiliates, officers, agents and employees from and against any and all losses, claims, damages, liabilities, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from any breach of Declarant's representations, warranties or certifications contained in this Form or from Declarant's willful misrepresentation or omission.

7. CONFIDENTIALITY AND USE OF INFORMATION

Recipient shall treat Personal Information received under this Form as confidential and shall not disclose such information except: (a) as authorized by Declarant; (b) to its service providers and agents to the extent necessary to carry out the permitted purposes, provided such parties agree to confidentiality obligations; or (c) as required by applicable law, regulation or court order, in which case Recipient shall provide prompt notice to Declarant unless legally prohibited.

8. NOTICES

9. AMENDMENTS AND WAIVER

No amendment, modification or waiver of any provision of this Form shall be effective unless in writing and signed by both parties. The waiver by either party of a breach of any provision of this Form shall not operate or be construed as a waiver of any subsequent breach.

10. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

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

11. COUNTERPARTS; AUTHORITY

This Form 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. If executed on behalf of an entity, the signatory represents and warrants that they are duly authorized to bind such entity.

12. CERTIFICATION

By signing below, Declarant certifies under penalty of perjury that the information and statements provided in this Form are true and correct to the best of Declarant's knowledge and that Declarant has read, understands and voluntarily agrees to the Consents and terms set forth herein.

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