Legal Statement of Applicant

LEGAL STATEMENT OF APPLICANT

This Legal Statement of Applicant is executed on Date: by Applicant Name: (Applicant) in favor of Recipient Name: (Recipient).

RECITALS

WHEREAS, Applicant has submitted information, representations and documentation to Recipient as part of an application, screening process, or other qualification procedure identified as Application Reference: ; and

WHEREAS, Recipient requires a sworn statement and authorizations from Applicant to verify Applicant's background, qualifications, and the truthfulness of the information submitted; and

WHEREAS, Applicant is willing to provide the representations, certifications and authorizations set forth below to induce Recipient to proceed with evaluation or processing of Applicant's matters.

NOW, THEREFORE, in consideration of the foregoing recitals and the mutual covenants contained herein, the parties agree as follows:

1. APPLICANT INFORMATION

2. STATEMENT AND CERTIFICATION

Applicant hereby certifies, represents and warrants to Recipient that the information provided in connection with the application and all attachments is true, complete and correct to the best of Applicant's knowledge. Applicant understands that Recipient will rely upon these representations in evaluating Applicant's qualifications.

Applicant declares the following (check all boxes that apply):

I have never been convicted of a felony.

I have never been subject to professional disciplinary action.

I am not presently subject to bankruptcy proceedings.

3. AUTHORIZATION

Applicant authorizes Recipient and its agents to obtain and verify information in connection with the application, including but not limited to criminal history, employment history, educational credentials, credit history to the extent permitted by law, and professional licensing records. This authorization extends to the release of records and information by former employers, educational institutions, law enforcement agencies and licensing authorities.

Consent to background checks: I consent

4. REPRESENTATIONS AND WARRANTIES

Applicant represents and warrants that: (a) all statements made in connection with the application are true, complete and not misleading; (b) Applicant will promptly notify Recipient in writing of any change in circumstances that would render any representation inaccurate; and (c) Applicant has not knowingly withheld any information that would be material to Recipient's determination.

5. ACKNOWLEDGMENTS AND PENALTIES

Applicant acknowledges that knowing and willful falsification, omission or misrepresentation of any material fact on this Statement may result in denial of the application, revocation of any offer or qualification, and may subject Applicant to civil or criminal penalties under applicable law.

6. CONFIDENTIALITY

Recipient will treat information provided by Applicant as confidential to the extent permitted by law. Applicant acknowledges that certain investigations may require disclosure of relevant information to third parties as part of verifications or legal compliance, and Applicant consents to such disclosures when necessary.

7. NOTICES

Notices delivered in accordance with the addresses provided will be effective upon receipt if delivered in person or within three business days if delivered by first class mail.

8. GOVERNING LAW

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

9. ENTIRE AGREEMENT

This Statement constitutes the entire agreement between Applicant and Recipient with respect to the subject matter hereof and supersedes all prior understandings, agreements and representations, oral or written.

10. SEVERABILITY

If any provision of this Statement is held invalid or unenforceable, the remaining provisions will continue in full force and effect and the invalid or unenforceable provision will be amended to the minimum extent necessary to render it valid and enforceable.

11. AMENDMENT AND WAIVER

No amendment, modification or waiver of any provision of this Statement will be effective unless in writing and signed by both Applicant and an authorized representative of Recipient. No waiver will constitute a waiver of any other right or future right.

12. COUNTERPARTS

This Statement may be executed in counterparts, each of which will be deemed an original and all of which together will constitute one and the same instrument. Signatures delivered by electronic means will be treated as original signatures for all purposes.

13. EXECUTION

The undersigned declare under penalty of perjury that the foregoing is true and correct and that they are authorized to execute this Statement on behalf of the party they represent.

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