Legal Non-Probation Form

LEGAL NON-PROBATION FORM

This Legal Non-Probation Form is entered into as of Effective Date: by and between Applicant Name: (the "Applicant") and Certifying Party Name: (the "Certifier"). The Applicant and the Certifier are collectively referred to herein as the "Parties".

RECITALS

WHEREAS, the Applicant seeks to be considered for engagement, employment, licensing, contracting, or participation in programs or activities for which the Certifier requires verification that the Applicant is not currently serving any court-ordered or administrative probation or supervised probation in any jurisdiction; and

WHEREAS, the Certifier requires a written representation and warranty from the Applicant regarding current probation status and the Applicant is willing to make such representation under penalty of law; and

WHEREAS, the Parties desire to set forth their respective rights and obligations with respect to the Applicant's current probation status and notification obligations in the event of any change in status.

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

1. DEFINITIONS

For purposes of this Form: (a) "Probation" means any period of court-ordered or administratively-imposed supervision, conditional release, community supervision, suspended sentence with conditions, or any similar requirement imposed by a criminal, juvenile, or administrative tribunal that restricts liberty or requires reporting to a supervising authority; and (b) "Material Misrepresentation" means any untrue statement or omission made by the Applicant that is material to the Certifier's decision to grant or maintain the Applicant's eligibility for the relevant position or benefit.

2. APPLICANT REPRESENTATIONS AND WARRANTY

The Applicant represents and warrants to the Certifier that as of the Effective Date: (a) the Applicant is not currently serving any form of Probation in any federal, state, territorial, tribal, or foreign jurisdiction; (b) the Applicant is not subject to supervised release, parole conditions, or diversion programs that would constitute Probation as defined herein; and (c) the Applicant has no outstanding court orders that impose reporting, monitoring, or supervision requirements that are equivalent to Probation.

Applicant Date of Birth: . Applicant Identification Number (if applicable):

3. DISCLOSURE AND NOTIFICATION OBLIGATION

The Applicant agrees to promptly notify the Certifier in writing if, after the Effective Date, the Applicant becomes subject to Probation or receives any criminal adjudication, plea agreement, deferred disposition, diversion agreement, or other disposition that would reasonably be construed as Probation. Such notification shall be given within Notification Period: business days of the Applicant becoming aware of the condition.

4. VERIFICATION AND CONSENT

The Applicant hereby authorizes the Certifier to make inquiries and obtain records, including criminal history and court records, to verify the truth and accuracy of the Applicant's representations. The Applicant's consent to such verification is given for the duration necessary to evaluate and, if applicable, maintain eligibility for the position or benefit at issue.

Applicant Consent to Verification

I consent to verification and background checks as described above.

5. FALSE STATEMENT; REMEDIES

The Applicant acknowledges that any false statement, omission, or Material Misrepresentation contained in this Form or in any supporting documentation shall constitute grounds for adverse action by the Certifier, including denial of engagement, termination of engagement, denial of licensing, or other remedies permitted by law. The Applicant agrees that the Certifier may rely on this representation and may take unilateral action upon discovery of falsity.

6. INDEMNIFICATION

The Applicant shall indemnify, defend, and hold harmless the Certifier, its officers, directors, employees, agents, successors and assigns from and against any and all claims, liabilities, losses, damages, costs, and expenses (including reasonable attorneys' fees) arising out of or related to any breach of the Applicant's representations or warranties herein, including any Material Misrepresentation.

7. CONFIDENTIALITY

Except as required by law or as reasonably necessary to exercise rights under this Form, the Certifier agrees to treat any information obtained pursuant to this Form as confidential and to restrict disclosure to persons with a legitimate need to know. Nothing in this provision limits the Certifier's obligations to report to governmental authorities as required by law.

8. NOTICES

All notices required or permitted under this Form shall be in writing and shall be delivered by personal delivery, nationally recognized overnight courier, or certified mail (return receipt requested) to the addresses set forth below or to such other address as a Party may designate in writing.

9. AMENDMENT; WAIVER

No amendment, modification, or waiver of any provision of this Form shall be effective unless in writing and signed by duly authorized representatives of both Parties. No waiver by either Party of any breach or default shall be deemed to be a waiver of any preceding or succeeding breach or default.

10. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the State of Governing State: without regard to its conflict of laws principles.

11. ENTIRE AGREEMENT; SEVERABILITY

This Form constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous negotiations, agreements, and understandings, whether written or oral. If any provision of this Form is held to be invalid, illegal, or unenforceable in any respect, the remaining provisions shall remain in full force and effect.

12. COUNTERPARTS; EXECUTION

This Form 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. Facsimile or electronic signatures shall have the same force and effect as original signatures.

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