Service Request Authorization Form

SERVICE REQUEST AUTHORIZATION FORM

Parties

Client Name:    Client Contact Title:

Service Provider Name:    Provider Contact Title:

Recitals

WHEREAS, Client requires certain services as described in this Service Request Authorization Form and desires to engage Provider to perform those services on the terms set forth herein; and

WHEREAS, Provider represents that it has the qualifications, experience, and personnel necessary to perform the requested services and agrees to perform such services in accordance with the terms of this authorization; and

WHEREAS, the parties intend for this document to authorize specific work, establish payment and timing, and define certain legal obligations between the parties.

Scope of Work

Itemized Services and Pricing

For each item below, provide a brief description, quantity or hours, unit price, and line total. Parties may attach additional schedules if required.

Payment Terms

Client agrees to pay Provider the amounts set forth above in accordance with the schedule below. All payments are due in U.S. dollars unless otherwise agreed in writing.

If any undisputed amount is not paid within days after the invoice due date, Client will pay a late fee equal to of the outstanding balance, calculated monthly, or the maximum permitted by law, whichever is less.

Unless otherwise stated, Client is responsible for all sales, use, value added, and other transactional taxes arising from payments to Provider. Check if Client will provide exemption: Exemption applicable

Term and Termination

This authorization commences on Start Date: and continues until End Date: , unless earlier terminated in accordance with this section.

Either party may terminate this authorization for convenience upon providing written notice at least days prior to the intended termination date. Either party may terminate for material breach if the breach is not cured within days after written notice specifying the breach.

Termination does not relieve Client of the obligation to pay for services performed and reasonable costs incurred through the effective date of termination, nor relieve Provider of obligations regarding return of Client property and confidentiality.

Confidentiality

Each party shall protect confidential information received from the other party using at least the same degree of care it uses to protect its own confidential information, but no less than a reasonable standard of care. Confidential information excludes information that (a) is or becomes publicly known through no breach by the receiving party, (b) was known by the receiving party prior to disclosure, (c) is lawfully received from a third party without restriction, or (d) is independently developed without use of the other party's confidential information.

The receiving party may disclose confidential information to the extent required by law, provided it gives the disclosing party prompt written notice and cooperates reasonably to seek protective measures.

By checking the box below, the signing party acknowledges and agrees to the confidentiality obligations set forth above.

Liability and Insurance

Provider will maintain, at Provider's expense, general liability and professional liability insurance coverage adequate for the services provided. Provider's aggregate liability to Client for any claim arising under this authorization shall be limited to the greater of the total amounts paid by Client to Provider under this authorization or the minimum limits of Provider's insurance coverage, except for liability arising from willful misconduct or gross negligence.

Governing Law; Entire Agreement

This authorization shall be governed by and construed in accordance with the laws of the state specified by the parties below, without regard to conflict of laws principles. Parties may select governing jurisdiction by entering the state name in the Governing Law field.

This Service Request Authorization Form, together with any attachments and schedules executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior proposals, representations, and communications, whether written or oral.

Additional Provisions

Authorization

By signing below, the undersigned represent and warrant that they are authorized to execute this Service Request Authorization Form on behalf of the party identified, that they have read and understood the terms set forth herein, and that the party agrees to be bound by those terms.

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