Legal Eligibility Declaration

LEGAL ELIGIBILITY DECLARATION

This Legal Eligibility Declaration (the Declaration) is made and entered into by Declarant Name: (Declarant) and Requesting Party Name: effective as of Date: .

RECITALS

WHEREAS, Requesting Party requires confirmation of Declarant's legal eligibility to perform duties, occupy positions, receive benefits, or otherwise engage in activities described by Requesting Party; and

WHEREAS, Declarant is willing to make representations and provide information necessary for Requesting Party to determine legal eligibility, subject to the terms and conditions set forth in this Declaration; and

WHEREAS, the parties desire to document the Declarant's representations, consents and the procedures by which Requesting Party may verify the Declarant's eligibility.

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

1. DEFINITIONS

For purposes of this Declaration, the following terms have the meanings set forth below: "Disqualifying Event" means any conviction, administrative suspension, professional discipline, statutory ineligibility, or other adjudicative determination that by law or policy prevents the Declarant from performing specified duties or holding specified status. "Verification" means any background, credential, immigration, licensing, criminal records, civil records, or other investigation reasonably necessary to determine legal eligibility.

2. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants to Requesting Party that, as of the effective date and continuing while this Declaration remains in effect:

(a) Declarant is legally authorized and has all necessary qualifications to perform the duties or hold the status identified by Requesting Party; Declarant's current legal name for this purpose is .

(b) Declarant is not subject to any Disqualifying Event that would, under applicable law or Requesting Party policy, prevent the Declarant from performing the relevant duties or holding the relevant status.

(c) Declarant's date of birth is and Declarant's identifying number (last four digits if applicable) is .

3. DISCLOSURE OF DISQUALIFYING EVENTS

Declarant shall disclose, in writing, any known Disqualifying Event existing at the time of execution or arising thereafter that materially affects Declarant's eligibility. Declarant certifies the following (check all that apply):

Prior felony conviction Professional license discipline Immigration status affecting eligibility

If any box above is checked, provide a full description of the event(s), dates, and disposition(s):

4. CONSENT TO VERIFICATION

Declarant expressly authorizes Requesting Party and its agents to obtain Verification of any statements in this Declaration, including but not limited to criminal history, professional licensure, employment history, immigration records, and educational credentials. Declarant acknowledges that refusal to consent may result in adverse action including denial of appointment, employment, engagement, or other privileges being sought.

Consent to Verification: I consent to verification as described above.

5. ONGOING OBLIGATION

Declarant shall promptly notify Requesting Party in writing of any event or condition that would reasonably be expected to alter or negate a representation made in this Declaration. Notification shall be given within five (5) business days of Declarant's actual knowledge of such event.

6. REMEDIES AND INDEMNIFICATION

If any representation in this Declaration is materially false or misleading, Requesting Party may take remedial action, including revocation of eligibility, removal from position, or termination of any agreement with Declarant. Declarant agrees to indemnify and hold harmless Requesting Party and its officers, directors, employees and agents from and against any claims, losses, liabilities, costs and expenses (including reasonable attorneys' fees) arising from Declarant's breach of any representation or warranty herein.

7. CONFIDENTIALITY

Except as required by law or as reasonably necessary to perform Verification and related administrative functions, Requesting Party shall maintain information provided by Declarant in confidence and shall not disclose such information to third parties without Declarant's prior written consent.

8. NOTICES

All notices required or permitted under this Declaration shall be in writing and delivered to the addresses below by personal delivery, certified mail, or other delivery service:

9. AMENDMENTS

No amendment, modification or waiver of any provision of this Declaration shall be effective unless made in writing and signed by both parties.

10. WAIVER

The failure of either party to enforce any right or provision under this Declaration shall not constitute a waiver of such right or provision unless acknowledged and agreed to in a writing signed by the waiving party.

11. GOVERNING LAW

This Declaration shall be governed by and construed in accordance with the laws of the jurisdiction indicated by Requesting Party's principal place of business as set forth in the Requesting Party notice address, without regard to conflict of law principles.

12. ENTIRE AGREEMENT

This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings of the parties.

13. SEVERABILITY

If any provision of this Declaration is held to be invalid, illegal or unenforceable, the remaining provisions shall continue in full force and effect and the parties shall negotiate in good faith a valid provision that achieves the original intent as closely as possible.

14. COUNTERPARTS AND ELECTRONIC SIGNATURES

This Declaration may be executed in counterparts, each of which when executed and delivered shall be deemed an original, and all of which together shall constitute one agreement. Electronic signatures and transmissions of executed counterparts shall be binding and have the same force and effect as original signatures.

CERTIFICATION

By signing below, Declarant certifies under penalty of perjury under applicable law that the information provided in this Declaration is true, complete and correct to the best of Declarant's knowledge and belief, and that Declarant understands the statements contained herein may be relied upon by Requesting Party.

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