Legal License Application Addendum

LEGAL LICENSE APPLICATION ADDENDUM

This Legal License Application Addendum (the Addendum) is made as of by and between Applicant Name: with principal address: (Applicant), and Licensor Name: with principal address: (Licensor). Applicant and Licensor are sometimes referred to herein individually as a Party and collectively as the Parties.

RECITALS

WHEREAS, Applicant submitted a license application identified as Application Number: dated ;

WHEREAS, the Parties desire to supplement and clarify certain representations, disclosures and supporting materials associated with the original license application and to set forth additional terms and conditions applicable to the review and processing of the application;

WHEREAS, the Parties agree that the provisions contained in this Addendum shall be incorporated into and shall form part of the application record and any license issued in connection therewith.

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

1. PURPOSE AND SCOPE

1.1 Purpose. The purpose of this Addendum is to provide supplemental disclosures, documentation and assurances to assist Licensor in its review of Applicant's license application and to establish the Parties' agreement as to the handling of supplemental information.

1.2 Incorporation. All representations, covenants and attachments provided with the original application remain in full force and effect except as expressly modified by this Addendum. In the event of any inconsistency between the application and this Addendum, this Addendum shall govern to the extent of the inconsistency.

2. APPLICANT INFORMATION AND ENTITY TYPE

Individual Corporation LLC Partnership Other

3. SUPPLEMENTAL REPRESENTATIONS AND WARRANTIES

3.1 Applicant hereby represents and warrants that, as of the date of this Addendum, all information submitted in the original license application and in any supplemental materials provided pursuant to this Addendum is true, complete and accurate in all material respects, and no material fact has been omitted or misstated.

3.2 Applicant further warrants that it will promptly notify Licensor in writing of any event or circumstance that would cause any representation or warranty to be untrue, inaccurate or incomplete.

4. SUPPORTING DOCUMENTATION

4.1 Applicant shall provide the following supplemental documents as part of the application record. Check each document provided:

Business plan or operating statement Financial statements (audited or reviewed) Proof of insurance or bond Resumes or credentials of key personnel Other supporting documentation

5. BACKGROUND CHECKS AND CONSENTS

5.1 Applicant consents to reasonable background, credit and regulatory checks as may be required by Licensor in connection with the processing of the application. Applicant authorizes Licensor to obtain such information from third parties and agrees to provide necessary releases and identifying information upon request.

5.2 Applicant represents that it has disclosed all individuals and entities that hold a direct or indirect controlling interest in Applicant and shall update such disclosures if any controlling interest changes during the application review period.

6. FEES AND COSTS

6.1 Applicant acknowledges that additional processing fees, investigation costs or compliance charges may be required in order to complete Licensor's review. Applicant agrees to pay any such fees assessed in accordance with Licensor's fee schedule.

7. CONFIDENTIALITY; USE OF INFORMATION

7.1 All non-public information provided by Applicant pursuant to this Addendum shall be handled in accordance with applicable confidentiality obligations. Licensor may use such information for the purpose of evaluating the application, conducting investigations, and issuing or conditioning any license.

7.2 Applicant acknowledges that Licensor may be required to disclose certain information by law, regulation, or valid legal process, and that such disclosures shall not constitute a breach of this Addendum.

8. NOTICES

Any notice required or permitted under this Addendum shall be in writing and shall be deemed given when delivered personally, sent by certified mail (return receipt requested), or delivered by nationally recognized overnight courier to the addresses listed below or to such other address as a Party designates by written notice.

9. AMENDMENT; WAIVER

9.1 This Addendum may be amended, supplemented or modified only by a written instrument executed by both Parties. No waiver of any provision of this Addendum shall be effective unless in writing and signed by the Party waiving compliance.

10. GOVERNING LAW; VENUE

This Addendum shall be governed by and construed in accordance with the laws of the state specified below without regard to its conflict of laws principles. The Parties submit to the exclusive jurisdiction of the courts located in the specified state for any action arising out of or relating to this Addendum.

11. ENTIRE AGREEMENT; SEVERABILITY

11.1 Entire Agreement. This Addendum, together with the original application and any documents expressly incorporated herein, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and communications, whether written or oral, relating to such subject matter.

11.2 Severability. If any provision of this Addendum is held to be invalid, illegal or unenforceable in any respect, such provision shall be severed and the remaining provisions shall continue in full force and effect.

12. COUNTERPARTS

This Addendum 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 delivered by electronic transmission shall be treated as original signatures.

13. CERTIFICATION AND PENALTIES

Applicant certifies under penalty of perjury that the information provided in this Addendum and in the application is true, correct and complete to the best of Applicant's knowledge. Applicant acknowledges that knowingly making a false statement or omission may subject Applicant to civil or criminal penalties and to denial, suspension or revocation of any license.

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