License Affidavit Form

LICENSE AFFIDAVIT FORM

This License Affidavit (the "Affidavit") is executed on by Affiant Name: , whose address is (the "Affiant"), in favor of Recipient Name: , whose address is (the "Recipient").

RECITALS

WHEREAS, the Affiant is the holder of a license described as License Type: issued by Issuing Authority: , identified by License Number: .

WHEREAS, the Recipient has requested written affirmation of the current status and material facts concerning the license for the purpose of Reliance Purpose: .

WHEREAS, the Affiant is willing to provide this sworn statement under oath for the Recipient's reasonable reliance.

NOW, THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the sufficiency of which is acknowledged, the Affiant declares and agrees as follows:

1. DEFINITIONS

In this Affidavit, unless the context otherwise requires, the following terms shall have the meanings ascribed to them: "License" means the license identified above; "Material Facts" means facts that would reasonably affect the validity, enforceability or status of the License; "Effective Date" means the date of execution entered above in execution_date.

2. AFFIANT'S REPRESENTATIONS AND WARRANTIES

The Affiant hereby warrants, represents and certifies under penalty of perjury that, as of the Effective Date:

(a) The License was issued on and, if applicable, is scheduled to expire on .

(b) The License is currently: Active Suspended Revoked (check all that apply)

(c) To the Affiant's present knowledge, there are no pending disciplinary actions, unresolved complaints, judgments or material proceedings against the Affiant that would impair the License or Affiant's authority to perform activities authorized by the License except as described in Material Facts below.

3. MATERIAL FACTS AND STATEMENT OF FACTS UNDER OATH

4. DISCLOSURE OBLIGATIONS

The Affiant covenants to notify the Recipient in writing within five (5) business days of any material change in the status of the License, including but not limited to suspension, revocation, lapse, or the initiation of any formal disciplinary proceeding. Notice shall be given to Recipient at the Notice Address set forth in Section 8.

5. USE AND LIMITATION OF RELIANCE

The Recipient may rely on the representations and certifications contained herein solely for the stated Reliance Purpose. This Affidavit does not constitute a warranty, guarantee or insurance policy and does not enlarge or modify the rights or obligations of any third party under the License or other applicable law.

6. INDEMNIFICATION

The Affiant agrees to indemnify, defend and hold harmless the Recipient, its officers, directors, employees and agents from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising from any material misrepresentation or omission by the Affiant in this Affidavit, except to the extent caused by the Recipient's gross negligence or willful misconduct.

7. REMEDIES

The Recipient shall be entitled to seek all available remedies at law or in equity for breach of this Affidavit, including but not limited to specific performance, injunctive relief, damages and recovery of reasonable attorneys' fees and costs. The rights and remedies provided herein are cumulative and not exclusive.

8. NOTICES

All notices, requests, demands or other communications required or permitted under this Affidavit shall be in writing and delivered to the parties at the addresses set forth below (or to such other address as a party may designate by notice in accordance with this Section).

9. AMENDMENTS; WAIVER

This Affidavit may be amended only by a written instrument signed by both parties. No failure or delay by any party in exercising any right shall operate as a waiver, nor shall any single or partial exercise of any right preclude other or further exercise of that right.

10. GOVERNING LAW

This Affidavit shall be governed by and construed in accordance with the laws of the state or jurisdiction where the Recipient's principal place of business is located, without regard to its conflicts of law principles.

11. ENTIRE AGREEMENT

This Affidavit constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written.

12. SEVERABILITY

If any provision of this Affidavit is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired.

13. COUNTERPARTS; EXECUTION

This Affidavit 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. Signatures transmitted by electronic means shall be binding.

14. CERTIFICATION AND OATH

The Affiant affirms under penalty of perjury under the laws of the applicable jurisdiction that the statements in this Affidavit are true and correct to the best of the Affiant's knowledge, information and belief.

Sign Now