Licence Renewal Application

LICENCE RENEWAL APPLICATION

Parties and Identification

Applicant Name:

WHEREAS Recitals

WHEREAS, Applicant Name: is the holder of the licence identified above issued by Licensing Authority: ; and

WHEREAS, Applicant seeks renewal of the licence on the terms and conditions set forth in this application and any resulting renewal agreement; and

WHEREAS, Licensing Authority has authority to accept or condition renewal subject to verification of information, payment of fees, and compliance with applicable statutory and regulatory requirements.

Applicant Contact & Business Information

Licence Details and Attachments

Original Issue Date:    Expiry Date:

Fee payment receipt

Proof of insurance or bond

Continuing education / compliance certificate

Scope of Work

Payment Terms for Renewal

Renewal Fee Amount: $

Late Fee:    Grace Period (days):

Term and Termination

Renewal Term Commencement Date:    Renewal Term Expiration Date:

Either party may terminate the renewal or any agreement thereunder for material breach after written notice and a cure period of days. Immediate termination may occur where required by applicable statute or where public health or safety is expressly jeopardized.

Confidentiality

The parties agree that any non-public business information, trade secrets, financial records, or personal data exchanged in connection with this renewal shall be maintained in confidence and used only for purposes of evaluating or administering the licence renewal. Disclosure is permitted to the extent required by law, regulation, or court order, provided the party required to disclose gives prompt notice to the other party where lawful to do so.

Representations, Warranties, and Certifications

By submitting this application the Applicant certifies under penalty of perjury that all information provided herein is true, complete, and accurate to the best of the Applicant's knowledge; that the Applicant has not been convicted of, nor subject to unresolved disciplinary action for, any offense materially affecting fitness to hold the licence; and that Applicant will comply with all applicable statutes, regulations, and licensing conditions during the renewal term.

Governing Law

This application, and any renewal agreement resulting from its approval, shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles.

Entire Agreement

The terms and conditions set forth in this application and any written approval or renewal instrument executed by the Licensing Authority constitute the entire agreement between the parties with respect to the subject matter hereof and supersede all prior agreements, representations, and understandings, whether written or oral. No amendment shall be effective unless in writing and signed by both parties.

Applicant Declarations (initial and check)

I declare that the information provided is true and complete.

I will comply with all license conditions, reporting, and inspection requirements.

No unresolved disciplinary or enforcement actions exist that would preclude renewal, except as described here:

Administrative Provisions

Processing time is subject to verification of submitted documents and payment. Licensing Authority reserves the right to require additional information, to suspend or condition renewal where public safety concerns exist, and to assess penalties for false statements or noncompliance.

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