PLEASE PRINT OR TYPE. ❑New Student ❑ Re-Entry Student Applicant Legal Name (First) (Middle) (Last) Social Security # - - Date of Birth _ - - Driver’s License / ID No. Home Telephone: ( ) - Work: ( ) - Cell: ( ) - Address City State Zip E-Mail
PLEASE PRINT OR TYPE. Use a separate registration form for each camper. Favor de escribir con letra de molde y a maquina. Xxxxx una forma por cada participante.
PLEASE PRINT OR TYPE. Name of Firm Representative Phone ( ) Mailing Address Fax ( ) City State ZIP E-Mail Address Name of person(s) attending the Trade Show: For booth sign and exhibitor’s directory, please complete the following: (PLEASE BE PRECISE AND PRINT OR TYPE TO AVOID ERRORS IN THE PRINTING OF NAME IDENTIFICATION SIGNS.) Company Name If you need electrical power to your booth, you will need to order and pay Convention Display Services directly. The approximate cost for electrical service is $110 plus tax. Convention Display Services will email you a booth agreement form approximately six weeks prior to the conference. Please mark Yes or No on this form and MS ACTE will forward your email address to Convention Display Services for the electrical service. Authorized Signature Printed Name Title (To be completed by MS XXXX) Date CONFIRMATION: The Mississippi Association for Career and Technical Education agrees to furnish booth(s). Booth assignment(s) will be provided upon arrival at the convention center on July 24, 2022. Amount Received $ Date Received Check Number Credit Card Number, Expiration Date, Security Code
PLEASE PRINT OR TYPE. NAME OF ORGANIZATION: LIC NO.: MAILING ADDRESS: PRINCIPAL MEETING ADDRESS: DAYS MEETINGS ARE HELD: TIME OF MEETINGS: NAME OF PRIMARY CONTACT: PHONE NO.: Officer Information (Three Required) Print Name & Title Phone No. ( ) DL# DATE OF BIRTH / / Business Address City State Zip Resident Address City State Zip Print Name & Title Phone No. ( ) DL# DATE OF BIRTH / / Business Address City State Zip Resident Address City State Zip Print Name & Title Phone No. ( ) DL# DATE OF BIRTH / / Business Address City State Zip Resident Address City State Zip STATUS OF ORGANIZATION (RELIGIOUS, CHARITABLE, ETC.): DATE ORGANIZATION CAME INTO EXISTENCE: LENGTH OF CONTINUED EXISTENCE: PURPOSE OF ORGANIZATION: INTENDED USE OF FUNDS REALIZED FROM SALE OF FIREWORKS: LOCATION OF FIREWORKS STAND: AMOUNT OF RENT $ NAME AND ADDRESS OF PROPERTY OWNER: I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION CONTAINED HEREIN IS TO THE BEST OF MY KNOWLEDGE AND BELIEF TRUE AND CORRECT. I FURTHER DECLARE THAT I HAVE READ THE RULES AND REGULATIONS WHICH CONCERN THE RETAIL SALE AND STORAGE OF FIREWORKS IN THE CITY AND WILL ABIDE BY THE CONTENTS THEREIN. SUBJECT TO THE ISSUANCE OF A LICENSE, I AGREE TO PROVIDE A FULL ACCOUNTING OF THE USE AND DISTRIBUTION OF FUNDS REALIZED FROM HOLDING SUCH LICENSE. (MUST BE SIGNED BY TWO [2] OFFICERS- PRESIDING OFFICER & ONE [1] OTHER) OFFICER’S SIGNATURE: TITLE: PRINT NAME: DATE: OFFICER’S SIGNATURE: TITLE: PRINT NAME: DATE: FOR REVENUE DIVISION USE ONLY PMT. DATE: AMOUNT PD.: REC. NO.: BY: Original White-Revenue Division Canary-Sheriff Pink-Applicant 1190 0609 000 XXXX XXXXXX XXXXXX, P.O. BOX 6234, CARSON, CALIFORNIA 90749 • (000) 000-0000 • FAX (000) 000-0000
PLEASE PRINT OR TYPE. Property Owner: Property Management Company (if applicable): Service Address: Applicant Data to be Used for Billing (full legal name and DBA if applicable): Name: In Care Of (c/o) if applicable: Complete Mailing Address: City: State: Zip: Telephone: Business ( ) ext. Home ( ) Signature: Title:
PLEASE PRINT OR TYPE. Property Owner: Co-owner: Property Address: City: State: Zip Code: Applicant Data to be Used for Billing Complete mailing address: City: _ State: Zip code: Telephone: Home _ Business: Cell: Email: Signature: _ Signature: Date: For Division Use Only: Account number: Account noted: D/L Rcvd: Date Received: Initials:
PLEASE PRINT OR TYPE. Complete Section A only if the Agent is contracting with the Company as an individual (in which case, all Agent level compensation will be paid to the Agent as an individual). Complete Section B only if the Agent is a busi- ness entity and this contract is between the Company and such entity (in which case, all Agent level compensation will be paid to the entity unless the Agent completes a separate Agent contract as an individual with the Com- pany). SECTION A SECTION B Individual Agent Name (Print or Type) Signature of Agent Social Security Number Business Entity Name (Print or Type) Signature of Authorized Officer Name of Authorized Officer (Print or Type) Federal Tax Identification Number Name of Managing General Agent (MGA) or General Agent (GA) Signature of SBLI USA Life Insurance Company, Inc. Officer This contract shall take effect on and subsequent con- tract years shall begin with the anniversary of this date. Agent Number
PLEASE PRINT OR TYPE. Name of Firm Representative_ Phone ( ) Mailing Address Fax ( ) City State ZIP E-Mail Address Name of person(s) attending the Trade Show: For booth sign and exhibitor’s directory, please complete the following: (PLEASE BE PRECISE AND PRINT OR TYPE TO AVOID ERRORS IN THE PRINTING OF NAME IDENTIFICATION SIGNS.) Firm Name Will you need electrical power to your booth? Yes No If you are planning to operate equipment in your exhibit booth, please indicate type of equipment The policies in the Trade Show Prospectus for the 2017 ACTE Conference are included as part of the contract. Authorized Signature Printed Name Title (To be completed by MS XXXX) Date CONFIRMATION: The Mississippi Association for Career and Technical Education agrees to furnish booth(s). Booth assignment(s) will be provided upon arrival at The Xxxxxxx Convention Center, Jackson, Mississippi on July 25, 2017. Amount Received $ Date Received
PLEASE PRINT OR TYPE. Princeton Municipal Utilities Account Number(s) (9 digits) Customer Name Business Name (if applicable) Service Address City, State, Zip Code Phone Number Authorized Signature Date Witnessed by CONDITIONS OF EQUAL PAYMENT AGREEMENT I confirm that I have a one (1) year billing history with Princeton Municipal Utilities. I acknowledge that Princeton Municipal Utilities will update their equal payment accounts at least twice a year, therefore the equal payment amount could be subject to change. Failure to make the monthly equal payment amount could result in termination of service unless your account has a positive balance. Activation Amount Date
