License Change Request

LICENSE CHANGE REQUEST AND AMENDMENT AGREEMENT

Parties and Recitals

This License Change Request and Amendment Agreement (the Agreement) is entered into between:

Licensor Name:

Licensee Name:

WHEREAS, Licensor granted Licensee a license identified by License Number: originally issued on ; and

WHEREAS, Licensee requests certain administrative and substantive changes to the license as set forth below and Licensor is willing to consider and, if agreed, to amend the license under the terms established in this Agreement.

Requested Change Details

Requested Effective Date:

Current License Address:

Select changes requested (check all that apply):

Change of registered name

Change of business address

Change of ownership / control

Modification of licensed scope / authorized activities

Add or remove licensed location(s)

Other (describe below)

Scope of Work

Supporting Documentation and Fees

Attachments supplied with this request (check all included):
Corporate formation / organization documents
Ownership / transfer documentation
Address verification / lease agreement
Other supporting documents

Administrative Fee Due:    Fee Payment Method:

Payment Terms (if applicable)

Amount Payable for Amendment:

Payment Schedule:

Late Fee: — Unpaid amounts shall bear interest and collection costs as provided herein.

Term and Termination

Amendment Start Date:    Amendment End Date (if any):

Either party may terminate this amendment for material breach after providing written notice and a cure period of days to cure the breach.

Confidentiality

Each party shall maintain in confidence any non-public information received from the other party in connection with this request and any subsequent amendment. Confidential information does not include information that is or becomes generally known to the public through no breach of this Agreement, is independently developed, or is rightfully received from a third party without restriction. The receiving party shall use confidential information solely for purposes of evaluating and implementing the requested license changes and shall not disclose such information except to employees, advisors, or contractors who have a legitimate need to know and are bound to confidentiality obligations no less protective than those set forth herein.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to choice-of-law principles that would apply the laws of another jurisdiction.

Entire Agreement and Amendments

This document, together with any attachments and approved supporting documents, constitutes the entire agreement between the parties with respect to the requested license changes and supersedes all prior or contemporaneous communications and proposals, whether electronic, oral, or written. No modification of this Agreement will be effective unless executed in writing by duly authorized representatives of both parties.

Certifications and Attestations

The undersigned certifies under penalty of perjury that the information provided in this License Change Request is true, complete, and accurate to the best of their knowledge, and that they are authorized to execute this request on behalf of the party named.

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