Common use of Please Print Clause in Contracts

Please Print. All fields required except e‐mail. Name: Birth Date: Height: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: ( ) E‐Mail: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE TO BE COMPLETED BY THE PARENT OR GUARDIAN IF PARTICIPANT IS UNDER THE AGE OF 18 ON THE DATE OF PROGRAM I am the parent or legal, court‐assigned guardian of the minor child whose name appears on this participation agreement. I have acknowledged receipt of the participation agreement, been given the opportunity to review the participation agreement, read its contents and am satisfied with, and in agreement with, the contents therein, having had the opportunity to discuss the same with the Provider and any third parties of my choosing. I, individually and as parent and/or guardian of my minor child do freely accept the terms of the participation agreement. I give my child permission to participate in the programs to be provided by Provider. My signature below reflects my agreement to fully release the Released Parties, as provided above, from any claim which I may have, and to release such persons on behalf of my child, for any claim the child may have. I further agree to indemnify the Released Parties for any claims of the child, or of any member of my or the child’s family, arising from the child’s enrollment or participation of the activities of the Provider. I further agree that my child shall be subject to the mandatory arbitration process described above. These agreements of release and indemnity include claims of negligence of a released party, including the negligence of any person or entity for whom a released party may be vicariously liable. Signature Date PARENT OR GUARDIAN SIGNATURE

Please Print. All fields required except e‐mail. NameDATE APPLICANT'S NAME CO-APPLICANT'S NAME CURRENT BILLING ADDRESS: Birth DateFUTURE BILLING ADDRESS: Height: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: PHONE NUMBER - Home ( ) E‐Mail- Work ( ) - PROOF OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include name of road, subdivision with lot and block number) PREVIOUS OWNER'S NAME AND ADDRESS (if transferring Membership) ACREAGE HOUSEHOLD SIZE NUMBER IN FAMILY LIVESTOCK & NUMBER SPECIAL SERVICE NEEDS OF APPLICANT The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. | NOTE: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE TO FORM MUST BE COMPLETED BY THE PARENT OR GUARDIAN IF PARTICIPANT IS UNDER THE AGE APPLICANT ONLY. A MAP OF 18 ON THE DATE OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM I am Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the parent or legal, court‐assigned guardian laws of the minor child whose name appears on State of Texas (hereinafter called the Corporation) and (hereinafter called the Applicant and/or Member), Witnesseth: The Corporation shall sell and deliver water water service to the Applicant and the Applicant shall purchase, receive, and/or reserve service from the Corporation in accordance with the bylaws and tariff of the Corporation as amended from time to time by the Board of Directors of the Corporation. Upon compliance with said policies, including payment of a Membership Fee, the Applicant qualifies for Membership as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth therein, a copy of which has been provided as an information packet, for which Member acknowledges receipt hereof by execution of this participation agreement. I A copy of this agreement shall be executed before service may be provided to the Applicant. The Board of Directors shall have acknowledged receipt the authority to discontinue service and cancel the Membership of any Member not complying with any policy or not paying any utility fees or charges as required by the participation agreementCorporation's published rates, been given the opportunity to review the participation agreement, read its contents and am satisfied withfees, and in agreement withconditions of service. At any time service is discontinued, terminated or suspended, the contents thereinCorporation shall not re-establish service unless it has a current, having had signed copy of this agreement. If this agreement is completed for the opportunity to discuss the same purpose of assigning utility service as a part of a rural domestic water and/or wastewater system loan project contemplated with the Provider and any third parties Rural Development, an Applicant shall pay an Indication of my choosing. I, individually and as parent and/or guardian of my minor child do freely accept the terms of the participation agreement. I give my child permission to participate Interest Fee in the programs to be provided by Provider. My signature below reflects my agreement to fully release the Released Parties, as provided above, from any claim which I may have, and to release such persons on behalf of my child, for any claim the child may have. I further agree to indemnify the Released Parties for any claims of the child, or of any member of my or the child’s family, arising from the child’s enrollment or participation of the activities of the Provider. I further agree that my child shall be subject to the mandatory arbitration process described above. These agreements of release and indemnity include claims of negligence lieu of a released party, including Membership Fee for the negligence purposes of any person or entity for whom a released party may be vicariously liable. Signature Date PARENT OR GUARDIAN SIGNATUREdetermining:

Please Print. All fields required except e‐mailApply these options to all properties listed below. NameOption 1(auto-transfer) Option 2 (disconnect notification) Billing Name Address Primary Phone Secondary Phone Service Address(es) of rental property (properties) to be automatically reverted to landlord’s name: Birth DatePLEASE PRINT I have read and understand the above conditions and hereby authorize Jasper County REMC to make such transfers as described above at the listed location(s) without further notice. SIGNATURE DATE This form will be in-force after all deposits and fees from the landlord are collected for each property listed above. Member (Tenant) Authorization to Release Information & Third-Party (Landlord) Notification for Disconnection of Service NOTE: Height: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: ( IT IS THE LANDLORD’S RESPONSIBILITY TO HAVE THIS FORM COMPLETED AND SUBMITTED TO JASPER COUNTY REMC (REMC) E‐Mail: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE IN ORDER TO BE COMPLETED BY THE PARENT OR GUARDIAN IF PARTICIPANT IS UNDER THE AGE RECEIVE NOTIFICATION OF 18 ON THE DATE DISCONNECTION OF PROGRAM I am ELECTRIC SERVICE DUE TO NON-PAYMENT TO REMC. This form shall be signed by both the parent member (tenant) and by the third party (landlord) to be notified in the event of possible disconnection of service due to non-payment to REMC. This rule shall not apply where a by-pass or legalother meter tampering method is discovered on a member’s premises, court‐assigned guardian or in the case of a member utilizing service in such a manner as to make it dangerous for occupants of the minor child whose name appears on this participation agreementpremises. I have acknowledged receipt In these cases, an immediate discontinuance of service to the premises will be imperative. In the event the premises are vacated with or without notice to the REMC or service is disconnected to the premises for any reason, Jasper County REMC is not responsible for any damages to the premises as a result of failure to deliver electric service even if notice is provided to the landlord. Landlord hereby waives any claim for damages to the premises occurring as a result of the participation agreementfailure to deliver electric service to the premises. Third-Party (Landlord) Notification Form Name of Member (Tenant) Service Address City, been given State, Zip Primary Telephone Number Secondary Telephone Number Third-Party (Landlord) to be notified in the opportunity event of possible disconnection of service for non-payment Billing Name Contact Name Telephone Number Street Address City, State, Zip I authorize Jasper County REMC to review release information to the participation agreementdesignated third party (Landlord). Signature of Member (Tenant) Signature of Third Party (Landlord) Date OFFICE USE ONLY: REMC location number Landlord Consent Agreement Cancellation Please list below the rental properties where you no longer want utility service to revert back into your name. This form must be submitted by the landlord who submitted the Residential Property Landlord Consent Agreement. In the event the premises are vacated with or without notice to the REMC or service is disconnected to the premises for any reason, read its contents and am satisfied with, and in agreement with, Jasper County REMC is not responsible for any damages to the contents therein, having had premises as a result of failure to deliver electric service even if notice is provided to the opportunity landlord. Landlord hereby waives any claim for damages to discuss the same with the Provider and any third parties of my choosing. I, individually and premises occurring as parent and/or guardian of my minor child do freely accept the terms a result of the participation agreementfailure to deliver electric service to the premises. I give my child permission to participate in Please sign, date and return the programs form to: Jasper County REMC XX Xxx 000 Xxxxxxxxxx, XX 00000 PLEASE PRINT ALL INFORMATION Billing Name Contact Name Street Address City, State, Zip Primary Phone Secondary Phone Service Address(es) to be provided by Providerremoved from program: Service address must match current REMC records. My signature below reflects my agreement to fully release the Released Parties, as provided above, from any claim which I may have, and to release such persons on behalf of my child, for any claim the child may have. I further agree to indemnify the Released Parties for any claims SIGNATURE DATE The cancellation of the child, or Residential Property Landlord Consent Agreement becomes effective after the REMC receives and processes this notice of any member of my or the child’s family, arising from the child’s enrollment or participation of the activities of the Provider. I further agree that my child shall be subject to the mandatory arbitration process described above. These agreements of release and indemnity include claims of negligence of a released party, including the negligence of any person or entity for whom a released party may be vicariously liable. Signature Date PARENT OR GUARDIAN SIGNATUREcancellation.

Please Print. All fields required except e‐mail. Name: Birth Date: Height: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: ( ) E‐Mail: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE TO Service Application and Agreement THIS FORM MUST BE COMPLETED BY APPLICANT ONLY DATE APPLICANT or COMPANY NAME OWN First M.I. Last CHECK ONE: RENT CO-APPLICANT/SPOUSE NAME SERVICE LOCATION / ADDRESS: (include name of road, subdivision with lot and block number) BILLING ADDRESS: Street Address or PO Box City State Zip PHONE: Home ( ) - E-MAIL ADDRESS: Cell ( ) - CHECK ONE: Work ( ) - PREFERENCE: E - Bill Paper Bill DRIVER'S LICENSE NO. APPLICANT DL # CO-APPLICANT A Copy of D.L. is needed MOVE-IN DATE: METER READING: APPLICANT’S EMPLOYER NAME & ADDRESS: Company Name Street Address City/State/Zip ACREAGE CHECK ONE: SITE-BUILT HOME DOUBLE-WIDE DUPLEX SINGLE-WIDE QUAD PLEX IF RESIDENCE, NUMBER IN FAMILY (one meter, one dwelling, standard service) IF BUSINESS, NAME & TYPE OF BUSINESS IF PURCHASING PROPERTY, A COPY OF DEED IS REQUIRED ♦ AN APPLICANT MAY PROVIDE A LETTER OF REFERENCE IN LIEU OF PAYING A SECURITY DEPOSIT IF THE PARENT LETTER FROM THE IMMEDIATE PAST UTILITY SHOWS NO PENALTIES, LATE PAYMENTS OR GUARDIAN IF PARTICIPANT IS UNDER DISCONNECTIONS INCURRED IN THE AGE PREVIOUS 12 MONTHS. ♦ REQUEST FOR CONFIDENTIALITY OF 18 ON THE DATE OF PROGRAM PERSONAL INFORMATION I am request any personal information held by the parent or legal, court‐assigned guardian District which is necessary for my water utility account be held as confidential at no charge and not be released to unauthorized persons. Authority exceptions are stated under House Bill No. 859. Initial: ♦ A partnership between JCSUD and CareFlite allows all customers of the minor child whose name appears on this participation agreementwater system to become members of CareFlite for $1 per month which covers all household members for CareFlite transport services. I have acknowledged receipt More details at JCSUD. - Can opt out at any time. OPT OUT of CareFlite Now Initial ♦ IF METER ACTIVATION IS REQUIRED, SPECIFY ONE OF THE FOLLOWING: Unlock meter, but leave water OFF in the participation agreement, been given the opportunity to review the participation agreement, read its contents and am satisfied withmeter box. Unlock meter, and in agreement with, the contents therein, having had the opportunity to discuss the same with the Provider and any third parties of my choosing. I, individually and as parent and/or guardian of my minor child do freely accept the terms of the participation agreement. I give my child permission to participate leave water ON in the programs meter box. Applicant authorizes the District to be provided by Providerunlock and leave meter in the ON position, even if no one is present at the service location when meter is unlocked. My signature below reflects my agreement to fully release the Released Parties, as provided above, from any claim which I may have, and to release such persons on behalf of my child, for any claim the child may have. I further agree to indemnify the Released Parties for any claims of the child, or of any member of my or the child’s family, arising from the child’s enrollment or participation of the activities of the Provider. I further agree that my child shall be subject to the mandatory arbitration process described above. These agreements of release and indemnity include claims of negligence of a released party, including the negligence of any person or entity for whom a released party may be vicariously liable. Signature Date PARENT OR GUARDIAN SIGNATURE.

Please Print. All fields required except e‐mail. NameIf applicable, name of organization or group requesting reservation: Birth DateName of Organization/Group: HeightName of Applicant: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: ( ) E‐Mail: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE TO BE COMPLETED BY THE PARENT OR GUARDIAN IF PARTICIPANT IS UNDER THE AGE OF 18 ON THE DATE OF PROGRAM I am the parent or legal, court‐assigned guardian of the minor child whose name appears on Individual authorized to sign this participation agreement. I have acknowledged receipt of the participation agreement, been given the opportunity to review the participation agreement, read its contents and am satisfied with, and in agreement with, the contents therein, having had the opportunity to discuss the same with the Provider and any third parties of my choosing. I, individually and as parent and/or guardian of my minor child do freely accept the terms of the participation agreement. I give my child permission to participate in the programs to be provided by Provider. My signature below reflects my agreement to fully release the Released Parties, as provided above, from any claim which I may have, and to release such persons on behalf of my child, for any claim the child organization/group Address: City: State: Zip Code: Phone Number: Other Number: Provide phone number that may have. I further agree to indemnify be contacted the Released Parties for any claims day of the childevent Park Facility Requested: Please note specific areas that would be utilized for the event or provide a sketch of the layout: Date(s) of Requested Reservation: Day(s) of Week Month Date(s) Year Time Requested (includes setup and take down): to Parks open at 6 a.m. and close at 10 p.m. Purpose of this request (i.e. concert, festival etc.): Approximate number of people expected to attend: Does your organization/group have liability insurance coverage? (check one below) ❒ YES - Please provide copy of proof of insurance ❒ NO Intoxicating alcohol will be dispensed on premises. (check one below) ❒ YES ❒ NO Note section on “Alcoholic Beverage Permit” in attached ordinance/guidelines. A copy of the permit must be on file with the Recreation Department before the event. Answer the following questions with a “yes” or “no” on the lines provided along with a description if stated. Will there be any of the following? A charge of admission to the event? A vendor, registration or entry fee for participants of the event? Concessions sold? If yes, a copy of the health department permit must be on file with the Recreation Department before the event. Selling of any member commodities or articles? If yes, list items being sold: “Kiddie rides” or other amusements? If yes, please describe/list type(s) of my or amusements: A Certificate of Liability Insurance must be on file with the child’s familyRecreation Department before the event. Amplified sound system? Live music? Any tents placed in the park area? If yes, arising from a sketch of tent placement must be submitted with application and contact Public Works Dept. at (000) 000-0000 one week prior to the child’s enrollment or participation event to approve tent placement. Please list any special needs (i.e. bathroom facilities, benches, trash cans): The Departments will do their best to provide the requests for your event. Applicant recognizes: That no fires are to be started except in facilities provided for that purpose; that fires must be extinguished; that the facility must be cleaned at the conclusion of its use; that applicants’ use of the activities facility may not interfere with the use made by others of the Provider. I further agree park facilities; that my child shall be subject to the mandatory arbitration process described above. These agreements of release all ordinances and indemnity include claims of negligence conditions of a released party, including the negligence of any person or entity for whom a released party may permit must be vicariously liable. Signature Date PARENT OR GUARDIAN SIGNATUREcomplied with.