Recertification Request Form

Recertification Request Form

Recitals

WHEREAS, the Applicant has previously been granted certification by the Certifying Authority and seeks renewal of that certification; and

WHEREAS, the Certifying Authority requires documentation and assurances that the Applicant continues to meet applicable standards and obligations for certification;

WHEREAS, the parties agree that submission of this Recertification Request and the accompanying documentation will enable the Certifying Authority to evaluate continued eligibility.

Applicant Information

Current Certification Details

Certification Type:

Certification ID Number:

Original Certification Date:    Current Expiration Date:

Scope of Work / Activities Since Last Certification

Describe work performed, training completed, or changes in status relevant to this recertification request.

Payment Terms

Applicable recertification fee (non-refundable):

Term and Termination

Certification Term Start Date:    Anticipated Term End Date:

Confidentiality

The Applicant and the Certifying Authority acknowledge that information submitted in connection with this Recertification Request may include confidential business information or personally identifiable information. Each party agrees to maintain the confidentiality of such materials in accordance with applicable law and the following obligations: (a) use submitted confidential information solely for purposes of evaluation and administration of certification; (b) restrict disclosure to employees or agents with a need to know and subject them to confidentiality obligations; and (c) employ reasonable safeguards to prevent unauthorized disclosure. Confidential information shall not include information that is or becomes publicly available through no breach by the receiving party or that is independently developed.

Supporting Documentation

Please indicate which documents are attached to this request (check all that apply):

Declarations and Certifications

By submitting this Recertification Request, the Applicant certifies that all information provided on this form and in any attachments is true, accurate and complete to the best of Applicant's knowledge. Applicant understands that false statements or material omissions may be grounds for denial, suspension or revocation of certification and may subject the Applicant to administrative penalties.

Governing Law; Entire Agreement

This Recertification Request and any action arising from it shall be governed by the substantive laws of the state or jurisdiction identified by the Certifying Authority. This form, together with any attachments and written agreements expressly incorporated by reference, constitutes the entire understanding between the Applicant and the Certifying Authority with respect to recertification procedures and supersedes all prior negotiations, representations and agreements, whether written or oral, relating to the subject matter herein.

Administrative Use Only

Certification and Signature

The undersigned Applicant affirms under penalty of law that the foregoing is true and correct and authorizes the Certifying Authority to verify any information provided.

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