Licensing Information Certificate

LICENSING INFORMATION CERTIFICATE

Recitals

WHEREAS, Licensing Authority: is duly authorized under applicable law to issue and regulate licenses for the activity described herein; and

WHEREAS, Licensee Name: (doing business as: ) has applied for or holds a license for the activities set forth below and seeks formal certification of licensing information;

WHEREAS, the parties desire to record the licensing status, scope, and material terms associated with the license referenced below for use in contractual, regulatory, and commercial contexts.

Licensing Details

Administrative Status

Current Status: Active Suspended Revoked Expired

Payment Terms (If Applicable)

License Fee Amount: $    Payment Schedule:

Late Fee (if past due):    Required Renewal Fee: $

Term and Termination

Term Commencement Date:    Term Expiration Date:

Either party may terminate this certification record upon written notice to the other party not less than days prior to the effective termination date. Termination does not relieve Licensee of obligations accrued prior to termination.

Confidentiality

The parties acknowledge that certain licensing records may contain confidential or proprietary information. Except as required by law or lawful order, neither Licensing Authority nor Licensee shall disclose confidential business information provided in connection with this certificate to third parties without the prior written consent of the disclosing party. The foregoing obligation shall not apply to information that is or becomes publicly known through no breach of this Certificate.

Governing Law

This Certification shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts of law principles.

Entire Agreement and Reliance

This Licensing Information Certificate, together with any attachments or endorsements expressly incorporated herein, constitutes the entire record of licensing information between the parties relating to the license identified above and supersedes all prior written or oral representations concerning the matters certified. Recipients of this certificate may rely on the representations contained herein until written notice of modification or revocation is provided by Licensing Authority.

Certification and Attestation

The undersigned Licensing Authority hereby certifies, under penalty of perjury and to the best of its knowledge and official records, that the information set forth in this document is true and accurate as of the date of signature below. The undersigned Licensee acknowledges receipt of this certificate and attests that the information provided to Licensing Authority for issuance of this certificate was true and complete when submitted.

Attestation: This certificate reflects current licensing status    Contains known limitations or endorsements

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