Legal Natural Person Form

LEGAL NATURAL PERSON FORM

This Legal Natural Person Form (the "Agreement") is made and entered into as of the day of , , by and between Company Name: with principal address: (hereinafter "Company"), and Natural Person Name: residing at: (hereinafter "Natural Person").

RECITALS

WHEREAS, Company requires written certification and representations from the Natural Person regarding the Natural Person's status, capacity and identity for corporate, compliance and administrative purposes; and

WHEREAS, Natural Person desires to provide such certification, to confirm that Natural Person is an individual natural person acting in a personal capacity and not as or on behalf of a legal entity, and to make the representations and consents set forth below; and

WHEREAS, the parties intend that this Agreement set forth the terms, representations and remedies applicable to such certification and related disclosures.

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

1. DEFINITIONS

1.1 "Personal Information" means any information that identifies or can be used to identify the Natural Person, including but not limited to name, residential address, date of birth, government-issued identification numbers, and place of birth.

2. REPRESENTATIONS AND WARRANTIES OF NATURAL PERSON

Natural Person hereby represents and warrants to Company that:

(a) Natural Person is a living natural person, of legal capacity to enter into contracts, and is acting in an individual capacity and not as an agent, officer, director, partner or representative of any legal entity except as has been expressly disclosed to Company in writing.

(b) Natural Person's full legal name is , and Natural Person was born on of , , in .

(c) Natural Person's government-issued identification is: Type: Number: Issuing jurisdiction: .

3. CERTIFICATION

Natural Person certifies, under penalty of law, that the foregoing representations are true and complete as of the Effective Date and will notify Company promptly if any material fact changes. Natural Person further certifies that Natural Person is not a legal entity and does not purport to bind any legal entity by signing this Agreement, except to the extent expressly authorized and separately disclosed in writing to Company.

Please confirm: I certify I am a natural person acting in my individual capacity.

4. AUTHORITY AND CAPACITY

Natural Person acknowledges that Company may rely on the representations and certifications provided herein in making business and compliance determinations. Natural Person authorizes Company to verify the Personal Information and to obtain and retain copies of government identification documents for verification and recordkeeping purposes.

5. USE, RETENTION AND DISCLOSURE OF PERSONAL INFORMATION

Company may use, store and disclose Personal Information only as reasonably necessary to satisfy legal, regulatory and contractual obligations, including identity verification and record retention. Company will maintain reasonable administrative, technical and physical safeguards to protect Personal Information against unauthorized access, disclosure or misuse.

6. INDEMNIFICATION

Natural Person agrees to indemnify, hold harmless and defend Company, its officers, directors and agents from and against any and all losses, liabilities, claims, damages, costs and expenses (including reasonable attorneys' fees) arising out of any breach of the representations and warranties in this Agreement or from any false or misleading statement made by Natural Person to Company.

7. LIMITATION OF LIABILITY

EXCEPT FOR LIABILITY ARISING FROM WILLFUL MISCONDUCT OR FRAUD, IN NO EVENT SHALL EITHER PARTY BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES ARISING OUT OF THIS AGREEMENT, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.

8. NOTICES

Notices under this Agreement shall be in writing and delivered to the respective notice addresses set forth above and shall be effective upon receipt.

9. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction selected by Company for governance, without regard to its conflict of law principles. The parties submit to the exclusive jurisdiction of the courts located in the chosen jurisdiction for resolution of disputes arising under this Agreement.

10. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, representations and understandings, whether written or oral. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

11. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties. Failure to enforce any provision shall not constitute a waiver of future enforcement. This Agreement may be executed in counterparts, each of which shall be deemed an original.

12. ADDITIONAL DECLARATIONS

The parties acknowledge that they have read, understood and accepted the terms of this Agreement.

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