User Information Statement

USER INFORMATION STATEMENT

Recitals

WHEREAS, User Name: (the "User") is providing personal, employment and contact information to Provider Name: (the "Provider") for the purposes described herein;

WHEREAS, the Provider requires the information set forth in this User Information Statement to evaluate eligibility, perform the agreed services, and to maintain administrative records; and

WHEREAS, both parties agree that the terms of engagement, payment, confidentiality, and other provisions set forth below shall govern the collection, use and protection of the information provided.

User Information

Employment / Affiliation

Emergency Contact

Scope of Work

The Provider shall use the information supplied by the User to provide the services described below. The specific deliverables, responsibilities and performance standards are set forth in the Scope of Work.

Payment Terms

Compensation: The User agrees to pay the Provider the amounts and on the schedule set forth below for services performed under this Statement. Payment terms are strict and timely payment is an express condition of continued performance.

Term and Termination

This Statement shall commence on Start Date: and shall continue until End Date: unless earlier terminated pursuant to the terms below.

Either party may terminate this Statement for convenience upon providing written notice at least days prior to the intended termination date. Termination for cause shall be effective immediately upon written notice where a material breach is not cured within 14 days of notice.

Confidentiality

Each party acknowledges that, in the course of performance, it may receive Confidential Information of the other party. "Confidential Information" means non-public information disclosed in any form that is designated as confidential or that reasonably should be understood to be confidential given the nature of the information and the circumstances of disclosure. Confidential Information excludes information that: (a) is or becomes generally available to the public through no act or omission of the receiving party; (b) was lawfully known to the receiving party prior to disclosure; (c) is rightfully received from a third party without restriction; or (d) is independently developed by the receiving party without use of the disclosing party's Confidential Information.

The receiving party shall use Confidential Information only to perform its obligations under this Statement and shall protect it with at least the same degree of care it uses to protect its own confidential information, but in no event less than reasonable care. The obligations in this paragraph survive termination for a period of three (3) years, or longer to the extent required by applicable law for certain categories of personal information.

I acknowledge and agree to the Confidentiality provisions above.

Governing Law

This Statement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that state for purposes of any dispute arising out of this Statement.

Entire Agreement

This Statement, together with any attachments or exhibits expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous agreements, proposals, or representations, whether written or oral. Any modification or amendment must be in writing and signed by authorized representatives of both parties.

Attestations and Consents

By signing below, the User certifies that all information provided in this User Information Statement is true, complete and accurate to the best of the User's knowledge. The User authorizes the Provider to use the information for the purposes described herein and to obtain verification of information from third parties as reasonably necessary to perform services.

I consent to the verification of the information provided and to the Provider's use of this information in accordance with the terms of this Statement.

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