Legal Examination of Identification Form

LEGAL EXAMINATION OF IDENTIFICATION FORM

This Legal Examination of Identification Form is entered into as of by and between Examiner Name: , Examiner Capacity: (\"Examiner\") and Subject Name: , Date of Birth: (\"Subject\").

RECITALS

WHEREAS, Examiner is engaged in the performance of duties that require confirmation of the identity of individuals with whom Examiner interacts; and

WHEREAS, Subject has presented one or more documents of identification and requests that Examiner examine and, if appropriate, retain records of such identification in accordance with the terms of this Form; and

WHEREAS, the parties desire to record the results of the identity examination, the method of verification, and the terms governing retention, use and disclosure of any records created as a result of the examination.

NOW, THEREFORE

In consideration of the mutual covenants set forth herein and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form: (a) \"Identification\" means any government-issued or institutionally-issued documentary evidence of identity presented by Subject; (b) \"Examination\" means the procedures performed by Examiner to verify that the Identification reasonably appears to relate to Subject; and (c) \"Records\" means copies, photographs, electronic images or notes made by Examiner in the course of the Examination.

2. EXAMINATION PROCEDURES

Examiner performed the following procedures to examine and verify Identification (check all that apply and describe where requested):

Procedures performed: Visual inspection of original document(s)
Comparison of photograph to Subject
Examination for security features or indications of alteration
Additional verification steps performed

If additional verification, describe:

3. IDENTIFICATION PRESENTED

Identification Record 1

Identification Record 2 (if applicable)

4. CERTIFICATION BY EXAMINER

Examiner certifies that the Examination was conducted in a careful and professional manner and that, to Examiner's best knowledge and belief, the Identification presented:

(a) appeared on its face to be genuine and unaltered; and (b) corresponded with the physical appearance of Subject at the time of Examination. Examiner further certifies that the information recorded in this Form is true and correct and may be relied upon by the parties and their successors.

Copies retained: Yes No

5. RETENTION, USE AND DISCLOSURE

Records created in the course of the Examination shall be retained only for the period necessary to fulfill the purposes for which they were created, or as required by applicable law. Retention period (enter a specific period or condition for destruction):

Use and disclosure of Records shall be limited to those persons and entities with a legitimate need to know for the purposes identified at the time of Examination. Subject consents to such limited use as indicated below:

6. REPRESENTATIONS AND WARRANTIES

Subject represents and warrants that the Identification presented to Examiner is valid, was lawfully obtained, and relates to Subject. Subject acknowledges that knowingly presenting false identification is subject to civil and criminal penalties under applicable law.

7. INDEMNIFICATION

Each party shall indemnify, defend and hold harmless the other party from and against any and all claims, liabilities, losses, costs and expenses (including reasonable attorneys' fees) arising out of the indemnifying party's breach of this Form or any misrepresentation in connection with the Identification.

8. LIMITATION OF LIABILITY

Except to the extent caused by willful misconduct or gross negligence, neither party shall be liable to the other for incidental, consequential, punitive or special damages arising from the Examination or retention of Records.

9. NOTICES

All notices under this Form shall be in writing and delivered to the addresses set forth below by hand, certified mail (return receipt requested), or other method that provides evidence of delivery.

10. AMENDMENTS; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing signed by the party granting the waiver. This Form may be executed in counterparts, each of which shall constitute an original and all of which together shall constitute one instrument.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

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

EXECUTION

The parties have caused this Form to be executed by their duly authorized representatives.

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