Legal Document Signatory Form

LEGAL DOCUMENT SIGNATORY FORM

This Legal Document Signatory Form, Document Title: is made effective as of (the "Effective Date"), by and between Party A: , with principal place of business or residence at , and Party B: , with principal place of business or residence at . Each of the parties listed above may be referred to herein individually as a "Party" and collectively as the "Parties."

RECITALS

WHEREAS, the Parties desire to record the identity of the authorized signatories and certain execution-related information pertaining to the Document identified above; and

WHEREAS, the Parties intend that signatures collected on this form shall evidence authorization to execute and deliver the Document and any related instruments, and to bind the Parties to the obligations set forth therein to the extent of their authority; and

WHEREAS, the Parties agree to provide customary representations and notices regarding authority, capacity, and contact information in order to facilitate reliance by counterparties and third parties.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth below, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

1. DEFINITIONS

1.1 Defined Terms. Capitalized terms used in this Form and not otherwise defined shall have the meanings given to them in the Document identified in the recitals. For purposes of clarity, "Authorized Signatory" means the individual whose printed name and signature appear below and who represents and warrants that he or she has the requisite authority to bind the Party on whose behalf the individual signs.

2. AUTHORITY AND REPRESENTATIONS

2.1 Authority. Each Party represents and warrants that it is duly organized and validly existing under the laws of its jurisdiction of organization, that the person executing this Form on its behalf is duly authorized to do so, and that execution, delivery and performance of the Document and this Form have been duly authorized and will not violate any agreement or law applicable to such Party.

2.2 Capacity. If a Party is signing in a representative capacity, the signatory warrants that he or she has authority to act in that capacity. Representative capacity (if applicable):

3. SIGNATORY INFORMATION

Individual   Corporation   Limited Liability Company   Partnership   Other

Individual   Corporation   Limited Liability Company   Partnership   Other

4. ATTACHMENTS AND DOCUMENT REFERENCES

The Parties acknowledge that the information provided in this Form is intended to supplement and confirm the identities and authorities of the executing parties for the Document and any schedules, exhibits or ancillary agreements referenced therein.

5. NOTICES

5.1 Notices. All notices required or permitted under this Form shall be in writing and shall be delivered to the addresses set forth below or to such other address as a Party designates by notice in accordance with this section. Notices shall be effective upon receipt.

6. ELECTRONIC SIGNATURES

6.1 Consent to Electronic Execution. Each Party consents to the use of electronic signatures to the extent permitted by applicable law and to the extent that the Document so permits. By checking the box below and signing this Form, the signatory consents that the electronic signature shall have the same force and effect as an original handwritten signature.

I consent to electronic signatures and agree that electronic signatures are binding.

7. ADDITIONAL COVENANTS

7.1 Reliance. Each Party acknowledges that third parties may rely upon the representations and authorizations contained in this Form and agrees to indemnify and hold harmless any third party that, in good faith, relies on the authority asserted by a signatory hereunder.

7.2 Continuing Effect. The representations and warranties contained in this Form shall survive the execution and delivery of the Document and any termination of the Document for a period necessary for the protection of third-party reliance.

8. MISCELLANEOUS

8.1 Governing Law. This Form shall be governed by and construed in accordance with the substantive laws of the jurisdiction specified by the Parties: , without regard to choice-of-law principles that would result in the application of the laws of any other jurisdiction.

8.2 Entire Agreement. This Form constitutes the entire agreement of the Parties with respect to the matters addressed herein and supersedes all prior understandings and agreements relating to such matters; provided, however, that this Form is not intended to and does not amend the substantive provisions of the Document unless expressly stated in writing and signed by the Parties.

8.3 Severability. If any provision of this Form is held to be invalid, illegal or unenforceable, the remaining provisions shall continue in full force and effect and the invalid provision shall be replaced by a valid provision that most nearly effects the Parties' original intent.

8.4 Amendments; Waiver. No amendment, modification or waiver of any provision of this Form shall be effective unless in writing and signed by the Party against whom enforcement is sought. No failure or delay by any Party in exercising any right shall operate as a waiver of that right.

8.5 Counterparts. This Form 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. Signatures transmitted by electronic imaging means shall be deemed originals for all purposes.

CERTIFICATION

Each undersigned certifies under penalty of perjury and as an authorized representative of the indicated Party that the information provided in this Form is true and correct to the best of the undersigned's knowledge, that the undersigned is authorized to sign on behalf of the Party, and that the Party agrees to be bound by the representations, warranties and covenants contained herein.

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