Legal Supplemental Application Form

LEGAL SUPPLEMENTAL APPLICATION FORM

This Legal Supplemental Application Form (the "Form") is made effective as of Effective Date: by and between Applicant Name: (entity type: Individual Corporation LLC Partnership), with principal address at ("Applicant"), and Recipient Name: (entity type: Individual Corporation LLC Partnership), with principal address at ("Recipient").

RECITALS

WHEREAS, Applicant submitted an original application identified as Application ID: dated (the "Original Application"); and

WHEREAS, Applicant provides the supplemental information and certifications set forth herein to correct, update, or supplement the Original Application and to assist Recipient in its review and decision-making; and

WHEREAS, Recipient requires execution of this Form as a condition to further processing of the Original Application.

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 hereby acknowledged, the parties agree as follows:

1. SUPPLEMENTAL INFORMATION

1.1 Applicant submits the following supplemental factual information to be incorporated into the Original Application. Applicant certifies that the statements below are true, correct, and complete to the best of Applicant's knowledge.

2. REPRESENTATIONS AND WARRANTIES

2.1 Applicant represents and warrants that all supplemental information provided in this Form and any attachments is accurate, complete, and not misleading. Applicant further warrants that it has authority to provide the information and to bind any entity on whose behalf this Form is submitted.

2.2 Applicant acknowledges that Recipient may rely on the representations and warranties in this Form in evaluating and acting on the Original Application, and that any material misstatement or omission may constitute grounds for denial, revocation, or rescission of any approval, permit, or license sought.

3. CERTIFICATIONS AND DISCLOSURES

3.1 Criminal and regulatory disclosures. Applicant affirms the following:

Has Applicant or any principal ever been convicted of a felony, or had a professional license suspended or revoked? Yes No

4. ATTACHMENTS AND EXHIBITS

4.1 Applicant attaches the following documents as part of this Form. Each listed attachment is incorporated by reference and shall be deemed part of this Form for all purposes.

5. PROCESSING, USE, AND RETENTION OF INFORMATION

5.1 Applicant understands and agrees that Recipient may use, copy, retain, and disclose the supplemental information in accordance with Recipient's policies and applicable law in connection with the Original Application and any related review, enforcement, or compliance proceedings.

5.2 Applicant grants Recipient a non-exclusive right to verify any information submitted and to obtain credit, criminal, civil, regulatory, and other background information as reasonably necessary to evaluate the Original Application.

6. CONFIDENTIALITY

6.1 Recipient will treat information designated in writing by Applicant as confidential to the extent permitted by law. Notwithstanding the foregoing, Applicant acknowledges that Recipient may be required to disclose information pursuant to legal process, public records law, or as otherwise required by law, and Recipient shall not be liable for such disclosures.

7. INDEMNIFICATION

7.1 Applicant agrees to indemnify, defend, and hold harmless Recipient and its officers, directors, employees, agents, and successors from and against any and all claims, liabilities, losses, damages, costs, and expenses (including reasonable attorneys' fees) arising out of or relating to any misrepresentation, omission, or breach of the representations, warranties, or certifications made by Applicant in this Form or any accompanying attachment.

8. LIMITATION OF LIABILITY

8.1 EXCEPT FOR CLAIMS ARISING FROM WILLFUL MISCONDUCT OR GROSS NEGLIGENCE, IN NO EVENT SHALL EITHER PARTY BE LIABLE TO THE OTHER FOR ANY SPECIAL, INCIDENTAL, CONSEQUENTIAL, OR PUNITIVE DAMAGES, INCLUDING LOSS OF PROFITS, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.

9. NOTICES

9.1 All notices, requests, consents, and other communications required or permitted under this Form must be in writing and delivered to the address provided below by hand, nationally recognized overnight courier, or certified mail (return receipt requested), and will be deemed given upon receipt.

10. AMENDMENTS; WAIVER; COUNTERPARTS

10.1 No amendment or modification of this Form will be effective unless it is in writing and signed by both parties. No waiver of any provision will be effective unless in writing and signed by the party granting the waiver, and any waiver applies only to the specific instance and shall not constitute a continuing waiver.

10.2 This Form may be executed in counterparts, each of which will be deemed an original and all of which together constitute one instrument. Signatures transmitted by electronic means, including scanned or electronic signatures, shall be binding for all purposes.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

11.1 Governing law. This Form will be governed by and construed in accordance with the laws of the State of without regard to principles of conflicts of law.

11.2 Entire agreement. This Form, together with the Original Application and any attachments referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous agreements, proposals, and communications, whether oral or written.

11.3 Severability. If any provision of this Form is held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, the remaining provisions will continue in full force and effect and the parties shall negotiate in good faith a substitute provision that reflects the parties' original intent as closely as possible.

12. MISCELLANEOUS

12.1 No third-party beneficiaries. Except as expressly provided, nothing in this Form shall confer any rights or remedies upon any persons other than the parties and their respective successors and permitted assigns.

12.2 Assignment. Neither party may assign its rights or delegate its obligations under this Form without the prior written consent of the other party, except that Recipient may assign to a successor entity in connection with a merger or sale of substantially all of its assets.

13. CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that the information provided in this Supplemental Application Form and any attachments is true, correct, and complete, and that Applicant understands that any willful misrepresentation may be punishable by law and may constitute grounds for denial or revocation of any approval or license.

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