TO BE COMPLETED BY. Home School Academic Advisor Please list the student's approved program applicable courses that are being completed at the host school: Course # Course Title # of Cr/Qtr Hrs. Academic Advisor Signature: Date: Print Name & Title of Advisor: Date: Email/Phone:
TO BE COMPLETED BY. EMPLOYER The Guarantor, , is employed with . The Guarantor is eligible for payroll deduction. The Guarantor’s payroll will be deducted in the amount of $ every (insert timing of payroll time period). The total amount of deduction will be , beginning on pay period beginning and ending on . Name and Title of Authorized Representative Signature Date 4 TO BE COMPLETED BY GUARANTOR/EMPLOYEE I, , the Guarantor, work for . I am paid every . I agree to pay GMHA, through payroll deduction, $ every . I understand that I am agreeing to deduct this payment from my wages or salary beginning on , in payroll periods – or until the amount due is paid in full. Guarantor’s (Employee’s) Signature Date 5 TERMS OF THIS AGREEMENT – By completing and submitting this agreement, the Guarantor/Employee agrees: • You will make each payment so that we receive it at the time specified in Boxes 4 and 5. If a scheduled payment will not be made, contact GMHA immediately. • This Agreement is based on your current financial condition. We may modify or terminate the agreement if our information shows that your ability to pay has significantly changed. You must provide updated financial information when requested. • If you default on your PR Deduction Agreement, or withhold information that may change or affect this agreement, GMHA may terminate this Agreement, pursue collection or utilize legal services to seek full payment of the balance due. • We can terminate your PR Deduction Agreement if you do not make installment payments as agreed, or you do not provide financial information when requested. • If we terminate your agreement, we may collect the entire amount you owe through legal proceedings, collections, or debt recovery service. • This agreement may require managerial approval. We will notify you when we approve or do not approve the agreement.
TO BE COMPLETED BY. STATION ONLY Ad submitted to station? ✔ Yes No Date ad received: Note: Must have separate PB-19 forms for each version of the ad (i.e., for every ad with differing copy). If only one officer, executive committee member or director is listed above, station should ask the advertiser/sponsor in writing if there are any other officers, executive committee members or directors, maintain records of inquiry and update this form if additional officers, members or directors are provided. Disposition: ✔ Accepted Accepted IN PART (e.g., ad not received to determine content)* Rejected – provide reason: *Upload partially accepted form, then promptly upload updated final form when complete. Date and nature of follow-ups, if any: Contract #: Station Call Letters: SYs 3267 & 9803 IC / DISH Date Received/Requested: 5.29.20 Est. #: Station Location: Effectv/ Atlanta Run Start and End Dates: 6.1-6.9.20 For national issue ads only (not required for state/local issue ads):
TO BE COMPLETED BY. X. Xxxxxxxx/Recruitment (pp. 1 – 3) Outreach worker or supervisor
TO BE COMPLETED BY. I. Outreach/Recruitment Outreach worker or supervisor
TO BE COMPLETED BY. YK#1 EMPLOYEE Employee's Family and Given Names (please print) Signature Relationship to Patient: Date:
TO BE COMPLETED BY. 1. Borrower acquires all of the shares in CFG (other than those held by WRC) pursuant to and in accordance with the CFG Share Sale Agreement. 5 Business days after Financial Close
TO BE COMPLETED BY. PURCHASER IF (a) ABOVE IS CHECKED The undersigned represents and warrants that it is purchasing this Security for its own account or an account with respect to which it exercises sole investment discretion and that it and any such account is a "qualified institutional buyer" within the meaning of Rule 144A under the Securities Act and is aware that the sale to it is being made in reliance on Rule 144A and acknowledges that it has received such information regarding the Company as the undersigned has requested pursuant to Rule 144A or has determined not to request such information and that it is aware that the transferor is relying upon the undersigned's foregoing representations in order to claim the exemption from registration provided by Rule 144A. Dated: ---------------- ---------------------------------------------------- NOTICE: To be executed by an executive officer If you want to elect to have this Security purchased by the Company pursuant to Sections 4.16 or 4.17 of the Indenture, check the appropriate box:
TO BE COMPLETED BY. PURCHASER IF (a) ABOVE IS CHECKED The undersigned represents and warrants that it is purchasing this Security for its own account or an account with respect to which it exercises sole investment discretion and that it and any such account is a "qualified institutional buyer" within the meaning of Rule 144A under the Securities Act and is aware that the sale to it is being made in reliance on Rule 144A and acknowledges that it has received such information regarding the Company as the undersigned has requested pursuant to Rule 144A or has determined not to request such information and that it is aware that the transferor is relying upon the undersigned's foregoing representations in order to claim the exemption from registration provided by Rule 144A. Dated: ------------------------ ---------------------------------------------- NOTICE: To be executed by an executive officer
TO BE COMPLETED BY. 1. Australian Borrower acquires all of the shares in CFG (other than those held by WRC) pursuant to and in accordance with the CFG Share Sale Agreement. 5 Business Days after Financial Close
