Legal Non-Conviction Certificate

LEGAL NON-CONVICTION CERTIFICATE

This Legal Non-Conviction Certificate (the Certificate) is made effective as of Date: by Applicant Name: whose current address is and Requesting Party: whose principal address is .

RECITALS

WHEREAS, Applicant has been requested by Requesting Party to provide a written certification concerning Applicant's criminal conviction history for the purpose(s) set forth herein; and

WHEREAS, Applicant is willing to provide a certification under penalty of law, and Requesting Party will rely upon such certification in connection with granting, maintaining, or otherwise administering employment, licensing, contracting, or other legal or regulatory privileges; and

WHEREAS, the parties wish to set forth the scope, limitations, and legal effect of Applicant's certification.

NOW, THEREFORE

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

1. CERTIFICATION OF NON-CONVICTION

1.1 Applicant hereby certifies, represents and warrants that, to Applicant's actual knowledge and except as disclosed in writing below, Applicant has not been convicted of any felony or misdemeanor, and there are no pending criminal charges against Applicant, in the following jurisdiction(s) for the time period specified: Jurisdiction(s): Time period from to .

1.2 Applicant affirms that no conviction for which Applicant has been convicted has not been subsequently sealed, expunged, vacated, or otherwise rendered legally invalid unless expressly disclosed herein. If any conviction has been sealed, expunged, vacated or otherwise set aside, Applicant shall describe such matters in the Disclosure Field below.

2. REPRESENTATIONS, WARRANTIES AND AUTHORITY

2.1 Applicant represents and warrants that the statements made in this Certificate are true, complete and correct in all material respects as of the date hereof and that Applicant has the full legal right and authority to make the representations contained herein.

2.2 Applicant acknowledges that this Certificate may be relied upon by Requesting Party and by agents, insurers, or governmental entities expressly authorized by Requesting Party for the purposes described in Section 4. Applicant further consents to such parties obtaining and verifying criminal history information and records to confirm the representations herein.

I authorize Requesting Party and its authorized representatives to obtain, review and rely upon criminal history information pertaining to Applicant for the purposes set forth in this Certificate.

3. USE, LIMITATION AND PERMITTED PURPOSES

3.1 Requesting Party may use and rely upon this Certificate solely for the following purposes: .

3.2 Requesting Party shall not disclose this Certificate or criminal history information obtained pursuant hereto except as required by law, regulation, or as reasonably necessary to its internal legal, compliance, or human resources personnel, or as otherwise authorized in writing by Applicant.

4. INDEMNIFICATION; REMEDIES

4.1 Applicant agrees to indemnify, defend and hold harmless Requesting Party from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from any materially false or misleading statement contained in this Certificate.

4.2 If it is determined that Applicant willfully made a false statement to obtain a benefit or to mislead Requesting Party, Requesting Party may terminate any authorization, employment, contract, license, or privilege extended as a result of reliance on this Certificate, and pursue any remedies available at law or in equity.

5. TERM; REVOCATION

5.1 This Certificate shall remain effective for the period specified here: Effective for months from the Effective Date, unless earlier revoked in writing by Applicant or terminated for cause by Requesting Party pursuant to Section 4.

6. NOTICES

7. MISCELLANEOUS PROVISIONS

Governing Law: This Certificate shall be governed by and construed in accordance with the laws of the jurisdiction specified here: without regard to conflict of laws principles.

Entire Agreement: This Certificate constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior written or oral agreements, representations, and understandings.

Severability: If any provision of this Certificate is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.

Amendments and Waiver: No amendment or waiver of any provision of this Certificate shall be effective unless in writing and signed by both parties. No failure or delay in exercising any right or remedy shall operate as a waiver.

Counterparts: This Certificate 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.

PENALTIES FOR FALSE STATEMENT

Applicant understands that knowingly making a false statement on this Certificate may subject Applicant to civil liability and criminal penalties under applicable law, including, but not limited to, fines and imprisonment where applicable.

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