CANCELLATION TERMS AND CONDITIONS :

IF YOU ARE AN EXISTING LICENSEE WHO IS FORMALLY REQUESTING TO TERMINATE YOUR AGREEMENT, USE THIS FORM TO SUBMIT YOUR REQUEST. IF YOU NEED TO ASSIGN OR MODIFY YOUR EXISTING CONTRACT, PLEASE SUBMIT AN ASSIGNMENT OR MODIFICATION FORM.

AS PART OF THIS TERMINATION REQUEST, AN EXHIBIT OF THE PROPERTY AND/OR COPY OF THE AGREEMENT AND YOUR CURRENT INSURANCE POLICY MUST BE PROVIDED. IF YOU HAVE AN OUTSTANDING BALANCE DUE, YOU MUST REMEDY PRIOR TO SUBMISSION OF THIS FORM. SEND THE OUTSTANDING PAYMENTS TO THE ADDRESS PROVIDED BELOW :

OmniTRAX Holdings Combined, Inc.
PO Box 209979
Dallas, TX 75320-9979

[SOME AGREEMENTS MAY NOT INCLUDE TERMINATION LANGUAGE, THIS APPLICATION WILL BE REVIEWED AND YOU WILL BE PROVIDED WITH A CONFIRMATION OF TERMINATION, IF APPLICABLE].

PLEASE INITIAL HERE TO INDICATE YOU UNDERSTAND THIS POLICY :

Railroad :

RR Acronym :

RR Record ID :

Licensee Entity Name :

Agreement Number :

Agreement Type :

Property Use:

Description of Agreement Location (Milepost, Address, Cross Street, Latitude and Longitude, etc.) :

Please attach the agreement files including a location exhibit :

Please attach the Certificate of Insurance here :

Agreement & Application Type :

The primary reason for the termination (select all that apply) :

Other :

If stated in the agreement, how many days of written notice is required for the termination?

Precise date of vacating the property ?

Detailed plans for Remediation and/or Restoration :

I/We understand and agree that the following terms and conditions, which may or may not be specified in my/our Contract, must be met prior to vacating the Property :

A. The Property will be left in the same or better condition as when rented, barring normal wear and tear. Any additional cleaning or remediation will completely be my/our responsibility. I/We understand that the giving of this notice does not relieve me/us of any liability that I/we have under the present Contract.

B. The Railroad must have the ability to inspect the Property as part of the request to terminate. If the Railroad determines the need for remediation, the termination request may be delayed until the Property is deemed to be satisfactorily remediated.

C. Any outstanding rental payments will be evaluated with this notice. If the Railroad determines there is a proration, that amount will be refunded within 90 days after the Property is vacated.
D. My/Our current insurance policy must accompany this request to terminate. The insurance policy must remain in effect per the terms outlined in the contract.

E. I/We have attached an exhibit depicting the precise area I/we are requesting to vacate.

I/we agree to all the above conditions and am/are providing my/our intent to terminate :

Yes

LIST CHECK NUMBER(S) FOR FINAL INVOICE (If applicable):

Applicant Contact Information

Applicant Contact First Name :

Applicant Contact Last Name :

Applicant Contact Email :

Applicant Contact Phone :

Application Date :

Signature :

Forwarding Address, City, State and Zip code :

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