Legal License Verification Form

Legal License Verification Form

This Legal License Verification Form is entered into on Effective Date: between Requesting Party: and Applicant Name: .

Recitals

WHEREAS, Requesting Party requires independent verification of Applicant's professional license and standing for purposes of credentialing, employment, contracting, or regulatory compliance; and

WHEREAS, Applicant has applied or will apply to Requesting Party and has provided information regarding the Applicant's license and authorizes release of licensing information to Requesting Party; and

WHEREAS, the parties desire to set forth the terms under which licensing authorities and other third parties may provide verification information to Requesting Party.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth herein, the parties agree as follows:

1. Definitions

In this Form, unless the context otherwise requires, the following terms have the following meanings: "Applicant" means the individual identified above; "Requesting Party" means the entity identified above; "Licensing Authority" means the governmental or private entity that issued the Applicant's professional license.

2. Authorization and Consent

Applicant hereby authorizes and consents to the release, disclosure and verification by any Licensing Authority, educational institution, employer, or other third party of records and information relating to Applicant's licensure, credentials, disciplinary history, sanctions, restrictions, and current licensure status to Requesting Party and its agents and representatives. Applicant expressly waives any claim against any Licensing Authority, Requesting Party, or their agents that may arise from such disclosure to the extent permitted by law.

3. License Information (Provided by Applicant)

Attorney    Medical / Healthcare    Contractor / Trades    Real Estate    Other:

Date Issued:    Expiration Date:    Current Status:   Active   Suspended   Revoked   Pending/Other

4. Verification Request

Requesting Party requests that Licensing Authority confirm the following items with respect to the above-identified license: (a) current status; (b) expiration date; (c) any restrictions, suspensions, revocations or disciplinary proceedings; (d) whether any fines, probations or conditions are currently imposed; and (e) any additional information that the Licensing Authority deems relevant.

5. Verification Response (To Be Completed By Licensing Authority)

Verification Date:    Confirmed License Number:

Active   Suspended   Revoked   Pending/Other

6. Representations and Warranties

Applicant represents and warrants that all information provided in this Form is true, complete, and correct to the best of Applicant's knowledge and that Applicant has not omitted any facts that would be material to Requesting Party's evaluation. Requesting Party represents that information received under this Form will be used solely for legitimate business, credentialing, licensing or regulatory compliance purposes and handled in accordance with applicable privacy laws.

7. Indemnification

Applicant agrees to indemnify, defend and hold harmless Requesting Party and any Licensing Authority and their respective officers, directors, employees and agents from and against any and all claims, liabilities, damages, losses and expenses (including reasonable attorneys' fees) arising out of or related to any false statements, omissions, or misrepresentations made by Applicant in connection with this Form, except to the extent such claim arises from gross negligence or willful misconduct of Requesting Party.

8. Confidentiality

Information disclosed pursuant to this Form may contain personal and confidential information. Requesting Party agrees to treat all such information as confidential and to limit disclosure to persons with a legitimate need to know, except as required by law, court order, or regulatory process.

9. Notices

10. Governing Law; Entire Agreement; Severability

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

11. Amendments; Waiver; Counterparts

Any amendment or modification to this Form must be in writing and signed by both parties. No waiver of any provision of this Form shall be effective unless in writing signed by the party against whom enforcement of the waiver is sought. This Form may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument.

12. Certification

By signing below, Applicant certifies under penalty of perjury that the information provided in this Form is truthful and that Applicant authorizes the release of licensing and disciplinary information to Requesting Party as described herein.

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