Legal History Document

LEGAL HISTORY DOCUMENT

This Legal History Document (the "Document") is entered into as of by and between Subject Name: , Subject Address: , Date of Birth: , Identification Number: (collectively, "Subject"), and Recipient Name: , Recipient Address: ("Recipient").

RECITALS

WHEREAS, Subject possesses certain records and history concerning criminal, civil, administrative, bankruptcy, and professional disciplinary matters (collectively, "Legal History"); and

WHEREAS, Recipient requires a complete and accurate Legal History from Subject for the Recipient's legitimate evaluation, licensing, employment, credentialing, or other lawful purpose; and

WHEREAS, Subject is willing to disclose and certify such Legal History under the terms and protections set forth in this Document.

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

1. DEFINITIONS

For purposes of this Document, the following definitions apply: "Legal History" means any and all records, judgments, convictions, charges, investigations, disciplinary proceedings, settlements, bankruptcy filings, and related documents concerning Subject; "Records" means copies of court filings, law enforcement records, administrative rulings, licensing board determinations, and other documentary evidence of Legal History.

2. DISCLOSURE AND CERTIFICATION

Subject certifies that the following checkboxed categories accurately reflect Subject's Legal History. Subject shall list particulars for each checked category in Section 3. Subject acknowledges that willful omission or material misrepresentation may constitute grounds for discipline, denial of licensure, termination of employment, or other adverse action.

Select applicable categories: Criminal Conviction Pending Criminal Charges Civil Judgment or Lawsuit Administrative/Professional Discipline Bankruptcy Filing Other

3. ITEMIZED LEGAL HISTORY

Subject shall provide a complete, itemized statement of each matter that is within the categories checked above. For each matter provide: (a) matter type; (b) court or agency and jurisdiction; (c) docket or file number if known; (d) date of initiation and final disposition; (e) final disposition and sentence or resolution; and (f) current status. If additional space is required, attach signed and dated schedules. Below, provide the primary summary.

4. AUTHORIZATION TO OBTAIN RECORDS

Subject authorizes Recipient and Recipient's agents to obtain Records from courts, law enforcement agencies, licensing boards, regulatory agencies, and other third parties reasonably believed to hold records relevant to Subject's Legal History. Subject hereby waives any right of confidentiality to the extent necessary to permit release of such Records to Recipient.

5. CONFIDENTIALITY; USE; RETENTION

Recipient shall treat all Records and disclosures as confidential and shall limit distribution and access consistent with applicable law. Recipient may use the Legal History only for the purpose stated in this Document. Recipient may retain Records for a period reasonably necessary to effectuate the purpose, not to exceed seven (7) years unless retained pursuant to a separate legal obligation. Recipient may disclose Records if compelled by law or a court order; in such event Recipient shall provide notice to Subject to the extent legally permitted.

6. REPRESENTATIONS AND WARRANTIES

Subject represents and warrants that: (a) the information provided in this Document and any attachments is true, complete and correct to the best of Subject's knowledge; (b) Subject shall promptly notify Recipient in writing of any material change to Subject's Legal History within ten (10) days of learning of such change; and (c) Subject has full authority to make the authorizations and releases contained herein.

7. RELEASE; LIMITATION OF LIABILITY

Subject releases and holds harmless Recipient, and Recipient's officers, directors, employees and agents, from any claims, damages or causes of action arising out of Recipient's lawful collection, verification, use, or retention of Records and information obtained under this Document, except to the extent such claims arise from Recipient's gross negligence or willful misconduct.

8. INDEMNIFICATION

Subject agrees to indemnify, defend and hold harmless Recipient from and against any loss, liability, damage, cost or expense (including reasonable attorneys' fees) arising out of any breach of Subject's representations or warranties in this Document, or arising from Subject's willful misrepresentation or omission of material facts.

9. NOTICES

All notices required or permitted under this Document shall be in writing and delivered to the addresses set forth below by personal delivery, certified mail, or overnight courier, and shall be deemed given upon receipt.

10. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Document shall be effective unless in writing and signed by both parties. No failure or delay by any party in exercising any right shall operate as a waiver. This Document may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Document shall be governed by and construed in accordance with the laws of the state or jurisdiction specified by Recipient at the time of signature. This Document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Document is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. REPRESENTATIVE CONTACTS

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