your full name
, the undersigned, hereby certify that the above provided information is true complete, and accurate. I hereby acknowledge that TLA may request additional information when reviewing this application and, that the final determination of this application remains at the complete and sole discretion of TLA.
In addition to being protected by copyright, all TLA systems and materials are covered by a
I acknowledge that I am obliged to comply with the
In the event that I am accepted as a QSP, I acknowledge that I and my organization, if any, will provide access only to clients in the "Supplied To" states or provinces listed on the TLA license purchase receipt. Where the regions listed in the TLA license purchase receipt do not include all the states or province for which that license purchase is intended, I will immediately provide to TLA a list of any further state or province for which the license purchase is intended. I acknowledge that I or my organization may be required to remit additional monies to TLA to meet my tax compliance or my organization’s tax compliance, as the case may be, as the result of my disclosure.
I acknowledge, understand, and agree that my selection as a QSP or termination, in the future as the case may be, shall be complete, final and at TLA’s sole discretion.
By checking this box, I hereby ‘sign’ this document, confirm that I am duly authorized to sign this document on behalf of my organization and certify the information provided herein.