Principal Information Form

PRINCIPAL INFORMATION FORM AND BUSINESS AGREEMENT

Parties and Recitals

Company Name:     Principal Name:

WHEREAS, Company requires identification, ownership and background information of individuals who qualify as principals in order to comply with contractual, regulatory and commercial requirements; and

WHEREAS, Principal represents that Principal is authorized to provide such information, certifies the accuracy of the information provided below, and agrees to the business terms set forth herein;

NOW, THEREFORE, in consideration of the mutual promises and covenants contained in this Principal Information Form and Business Agreement, the parties agree as follows:

Principal Information

Entity / Business Information

Entity Type: Corporation LLC Partnership Sole Proprietorship Other

Ownership and Authority

Percent Ownership Held by Principal:

Principal holds authority to bind the entity in business matters described in this form: Yes No

Background & Compliance

Has the Principal ever been convicted of a felony or been subject to licensing discipline that would materially affect performance of duties? Yes No

Scope of Work

Describe the principal duties, responsibilities or services to be provided (if applicable). This description may be used to determine applicable indemnities, insurance, and compliance requirements.

Payment Terms (if applicable)

Compensation Amount:

Late Payment Fee:

Term and Termination

Term Commencement Date:     Term Expiration Date:

Either party may terminate this agreement for convenience upon written notice to the other party delivered at least days prior to the effective termination date. Termination for cause may be immediate if the non-breaching party provides written notice describing the breach and the breaching party fails to cure within a commercially reasonable period.

Confidentiality

Principal and Company acknowledge that during the course of their relationship each may receive or have access to Confidential Information. Confidential Information includes, without limitation, business plans, financial data, trade secrets, customer lists, pricing, technical information and all other non-public information disclosed in any form. Each party shall: (a) hold Confidential Information in strict confidence; (b) use Confidential Information solely to perform obligations under this form; and (c) not disclose Confidential Information to any third party except to employees, agents or advisors on a need-to-know basis who are bound by confidentiality obligations no less protective than those in this section. Upon termination or request, each party shall promptly return or certify destruction of Confidential Information. Monetary damages may be inadequate relief for actual or threatened breach; injunctive or equitable relief shall be available in addition to other remedies.

Governing Law

This form and any dispute arising out of or relating to it shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that state for resolution of disputes.

Entire Agreement

This Principal Information Form, together with any attachments, exhibits and written schedules executed by the parties, constitutes the entire agreement between Company and Principal with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. No amendment or waiver shall be effective unless in writing and signed by an authorized representative of each party.

Certification and Authorization

Principal certifies that the information provided in this form is true, complete and correct to the best of Principal's knowledge and understands that providing false or misleading information may constitute a material breach and may subject Principal to legal liability. Principal authorizes Company to verify any information provided herein and to request background, credit and reference checks as reasonably necessary for regulatory compliance or business purposes.

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