Occupational License Verification Form

OCCUPATIONAL LICENSE VERIFICATION FORM

This Occupational License Verification Form is made and entered into by Verifying Entity: with mailing address and Applicant: whose date of birth is / / .

RECITALS

WHEREAS, Applicant has applied for or holds an occupational license and requests verification of licensure status by the Verifying Entity for purposes of employment, credentialing, or regulatory compliance; and

WHEREAS, Verifying Entity maintains records relating to occupational licenses and is authorized to confirm licensure status to third parties upon proper request and applicant authorization; and

WHEREAS, the parties desire to set forth the terms and conditions governing the preparation, release, use and limitations of the verification of Applicant's occupational license.

NOW, THEREFORE

In consideration of the mutual promises contained herein, and for other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. Definitions

1.1 "License" means the occupational license, certificate, registration or permit issued to Applicant by an issuing authority identified in Section 2. "Verification" means the definitive confirmation of the License status provided by Verifying Entity in writing or certified electronic record.

2. License Information to be Verified

Applicant requests verification of the following license:

License Status (check all that apply): Active Inactive Suspended Revoked Other

3. Authorization and Release

Applicant hereby authorizes Verifying Entity to release to Verifying Entity's designated recipient(s) the information requested in Section 2. Applicant acknowledges that such disclosure may include confirmation of licensure status, issuance and expiration dates, and any disciplinary actions recorded by the Issuing Authority. Applicant expressly releases Verifying Entity, its officers, agents and employees from any liability arising from the release of such information in accordance with this form.

4. Verification Response and Timing

Upon receipt of a properly completed request and payment of any required fee, Verifying Entity shall use commercially reasonable efforts to provide written verification within thirty (30) calendar days. Verification shall be provided by a signed or certified statement on Verifying Entity letterhead or other authenticated electronic record that expressly identifies the License and the information verified.

Fees: Applicant agrees to pay any statutorily permitted fee or administrative fee charged by Verifying Entity. If a fee is required, indicate method of payment and amount.

5. Confidentiality and Use Restrictions

Information obtained through this Verification is confidential and shall be used solely for the Purpose of Verification stated above. Recipient of the Verification shall not reproduce, distribute, or disclose verification information to any third party except as required by law or necessary to accomplish the stated purpose. Recipient must destroy or return copies of the Verification upon request by Applicant or Verifying Entity.

6. Representations, Warranties and Liability

Applicant represents and warrants that the information provided in this Form is true and correct to the best of Applicant's knowledge. Verifying Entity warrants only that it will exercise reasonable care to report accurately the information reflected in its official records. Except as expressly provided herein, neither party makes any other warranty, express or implied. To the maximum extent permitted by law, Verifying Entity's liability for inaccuracies in verification shall be limited to direct damages and shall not include consequential, incidental, or punitive damages.

7. Notices

All notices, requests or demands required or permitted under this Form shall be in writing and delivered to the addresses set forth below. Notice is effective upon personal delivery or three (3) calendar days after deposit in the United States mail, postage prepaid, addressed as follows:

8. Amendments; Waiver; Severability; Entire Agreement; Counterparts

This Form may be amended only by a written instrument executed by both parties. No waiver of any breach shall constitute a waiver of any other breach. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. This Form may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument.

9. Governing Law

This Form shall be governed by and construed in accordance with the laws of the state selected by the parties. The parties consent to the exclusive jurisdiction of the state and federal courts located therein for any disputes arising under this Form.

10. Additional Instructions and Certifications

Applicant certifies under penalty of perjury that the information provided in this Form is true and correct and that Applicant is the person identified herein. Applicant further authorizes release of the requested verification information for the purpose specified above.

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