License Exemption Form

LICENSE EXEMPTION AGREEMENT AND APPLICATION

Parties

Applicant Name:

Recitals

WHEREAS, Applicant conducts or proposes to conduct specified business activities described herein and seeks an exemption from a licensing requirement otherwise applicable to those activities; and

WHEREAS, Issuing Party has authority to grant exemptions from licensing requirements under applicable rules and elects to consider this application based on the representations and supporting documentation submitted by Applicant; and

WHEREAS, the parties desire to set forth the terms under which an exemption will be granted, including scope, duration, conditions, and payment obligations.

Application Details

Sole Proprietor    Limited Liability Company (LLC)    Corporation    Partnership    Other:

Exemption Requested

Payment Terms

Fee Amount: $    Payment Schedule:

Late Payment Fee: . All late fees are calculated on outstanding balances until paid in full.

Applicant acknowledges that payment obligations under this Agreement are independent of the Issuing Party's exercise of discretion to grant an exemption; non-payment may result in suspension or revocation of any granted exemption.

Term and Termination

Effective Date: .    Expiration Date:

Either party may terminate this Agreement for cause upon written notice to the other party if the other party materially breaches any obligation and fails to cure within days after receipt of written notice. Termination may also occur immediately where required by law or where continued exemption would pose a substantial public risk.

Confidentiality

The parties acknowledge that information submitted in support of this application may include confidential business information. Issuing Party agrees to protect confidential information from unauthorized disclosure in accordance with its policies and applicable law. Applicant shall clearly mark information claimed to be confidential and provide a written statement asserting the basis for confidentiality. Confidential information does not include information that (a) is or becomes publicly available without breach of this Agreement, (b) is independently developed by Issuing Party, or (c) is legally compelled to be disclosed.

Representations and Warranties

Applicant represents and warrants that all information furnished to Issuing Party in connection with this application is true, complete, and accurate to the best of Applicant's knowledge; that Applicant has authority to execute this Agreement; and that Applicant will comply with any conditions attached to a granted exemption. Any materially false or misleading representation is grounds for denial, suspension, or revocation of the exemption and may subject Applicant to penalties.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of , without regard to conflict of laws principles. Any dispute arising under this Agreement that is not resolved by negotiation shall be resolved under the exclusive jurisdiction of the courts located within that jurisdiction.

Entire Agreement

This Agreement, including any attachments and the representations and supporting documents submitted by Applicant, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements, understandings, or representations. Any amendment to this Agreement must be in writing and signed by both parties.

Certification

By signing below, Applicant certifies under penalty of perjury that the statements and information provided in this application and any attachments are true, accurate, and complete. Applicant acknowledges that Issuing Party may verify any representation and that falsification may result in denial or revocation of the exemption and may trigger civil or criminal penalties.

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