Legal PGC Application

LEGAL PGC APPLICATION

Applicant Name:   Applicant Address:

Certifying Body Name:   Certifying Body Address:

RECITALS

WHEREAS, Applicant seeks issuance of a PGC (Professional Guardianship/Protectorate Certification) authorizing the Applicant to act in the capacity described in this application under the terms and conditions herein; and

WHEREAS, Certifying Body administers the review, investigation and issuance of PGCs and requires submission of this application together with supporting documentation, background authorization, and certification under oath; and

WHEREAS, the parties desire to establish the credentials, representations, and legal undertakings necessary for the consideration of the application.

NOW, THEREFORE, in consideration of the mutual covenants and representations contained in this Application, Applicant submits the following information and certifications to the Certifying Body for evaluation and determination.

1. DEFINITIONS

For purposes of this Application, the following terms shall have the meanings ascribed: "Applicant" means the person or entity identified above; "PGC" means the Professional Guardianship/Protectorate Certification sought; "Certifying Body" means the organization identified above that will issue a determination. Other defined terms are used in the text and construed consistently with ordinary legal usage.

2. APPLICANT INFORMATION

Individual    Corporation    Nonprofit    Other:

3. ELIGIBILITY AND BACKGROUND AUTHORIZATION

Applicant affirms that all information provided in this Application and all supporting documents are true, complete and accurate to the best of Applicant's knowledge. Applicant hereby authorizes the Certifying Body, its authorized representatives and contractors to conduct such background investigations, reference checks, and verification of information as required, including criminal history, professional licensing status, and employment history.

Applicant consents to background checks and releases any party from liability for providing information in accordance with such checks.

4. REQUIRED ATTACHMENTS AND SUPPORTING DOCUMENTS

Applicant must submit the documents checked below with this Application. Failure to submit required documentation may result in denial or delay.

Resume/CV    Professional References (minimum two)    Copies of Professional Licenses or Certificates

Government-issued Photo ID    Other Documents:

5. FEE AND PAYMENT

Applicant shall pay the non-refundable application fee required by the Certifying Body. Payment must accompany submission unless alternative arrangements are authorized in writing by the Certifying Body.

6. REVIEW, DETERMINATION, AND APPEALS

The Certifying Body will review the Application and supporting materials and may request additional information. The Certifying Body's determination to grant, conditionally grant, or deny the PGC will be issued in writing and will include the grounds for any denial or conditioning. Applicant may request reconsideration in accordance with the procedures set by the Certifying Body.

7. REPRESENTATIONS, WARRANTIES AND CERTIFICATIONS

Applicant represents and warrants that: (a) Applicant has the authority to submit this Application and to make the certifications herein; (b) all statements and documents submitted with this Application are true, complete and not misleading; (c) Applicant will comply with applicable statutes, rules, and regulations governing the activities authorized by a PGC; and (d) Applicant understands that willful misrepresentation or omission of material facts may constitute grounds for denial or revocation and may be punishable under applicable law.

8. CONFIDENTIALITY

Information submitted may be retained as part of Certifying Body records. Where applicable, Certifying Body will treat personal information consistent with its policies and with applicable law; however, documents and information may be disclosed if required by law or in connection with enforcement or appeals.

9. NOTICES

Any notice, demand or communication required or permitted under this Application shall be in writing and delivered to the addresses set forth above or to such other address as a party may designate in writing. Notice is effective upon actual receipt or three (3) business days after deposit with the U.S. Postal Service, postage prepaid.

10. GOVERNING LAW

This Application and any determination issued by the Certifying Body shall be governed by and construed in accordance with the laws of the State selected by the Certifying Body, without regard to principles of conflict of laws that would result in the application of the laws of another jurisdiction.

11. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT

This Application, together with any attachments and supplemental materials submitted herewith, constitutes the entire agreement between Applicant and Certifying Body regarding the subject matter hereof and supersedes all prior communications. If any provision of this Application is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Application may be amended only by a written instrument signed by both Applicant and an authorized representative of the Certifying Body.

12. WAIVER; COUNTERPARTS

No waiver of any provision of this Application shall be effective unless in writing and signed by the party waiving the provision. This Application 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.

13. ACKNOWLEDGMENT AND CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that the information provided in this Application and attachments is true, complete and correct to the best of Applicant's knowledge, and acknowledges that false statements may result in criminal or civil penalties and denial, revocation or disciplinary action by the Certifying Body.

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