Print Name. Signature: Date:
Print Name. Age: Date of Birth: / / Male Female Home Address: Home Tel.: ( ) X / / Signature of Participant Date Signed
Print Name. Notary Public /s/ Patricia A. Frank Commission Xx.: My Commission Expires: STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this 1st day of March, 2000 by Jeffery B. Weinress, as President of GEC ACQUISITION CORPORATIOX, x Xxxxxx xxxxxxxtion, on behalf of said corporation. Said person (check one) |x| is personally known to me, |_| produced a driver's license (issued by a state of the United States within the last five (5) years) as identification, or |_| produced other identification, to wit:_______________________.
Examples of Print Name in a sentence
Owner First Witness Print Name Print Name Second Owner (if applicable) Address Print Name Second Witness Print Name Address STATE OF FLORIDA COUNTY OF PINELLAS The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this day of , 20 by who is/are personally known to me or who has/have produced as identification.
By: Print Name: Title: Date: _______________________________ Tax ID Number: By: Print Name: Title: Date: _______________________________ MERCEDES-BENZ EXTRA, LLC By: Print Name: Title: Date: _______________________________ CONFIDENTIALITY AND PROPRIETARY RIGHTS AGREEMENT (Employee of Independent Agency) , (“Contractor”) of (“Agency”), acknowledges that in connection with providing services to Mercedes-Benz U.S. International, Inc.
VENDOR: (Name of Vendor) Date: , 2024 By: (Signature) Name: (Print Name) Its: (Title) END OF DOCUMENT EXHIBIT D INSURANCE VENDOR shall provide, in addition to the Certificates of Insurance, original Endorsement affecting the coverages specified in herein on the attached form.
APPROVED BY: TEXAS DEPARTMENT OF TRANSPORTATION By: [Printed Name] By: Authorized Signature District Engineer (or designee) Date: OWNER By: [Print Owner Name] By: Duly Authorized Representative [Title] [Company] Date: DB CONTRACTOR By: [Print Name] By: Duly Authorized Representative [Title] [Company] Date: EXHIBIT A PLANS, SPECIFICATIONS, COST ESTIMATES AND ALLOCATION EXHIBIT B UTILITY ADJUSTMENT AGREEMENT AMENDMENT (DB-ROW-U-UAAA-DM) County: ROW CSJ No.: Const.
Lee County Board of County Commissioners GRANTEE By (Authorized Signature) Xxxxx Xxxxxx, Chairman Print Name and Title of Person Signing Date Signed State of Florida Department of Environmental Protection DEPARTMENT By Secretary or Designee Date Signed Xxxx Xxxx, Director of the Office of Resilience and Coastal Protection Print Name and Title of Person Signing ☐ Additional signatures attached on separate page.
More Definitions of Print Name
Print Name. Its: _________________________________ EXHIBIT "C" - Page 1 Initials: _________ _________ EXHIBIT "D" ----------- CERTIFIED COPY OF BOARD OF DIRECTORS RESOLUTIONS OF INTERPLAY ENTERTAINMENT CORP. ----------------------------- The undersigned, being the duly elected Corporate Secretary of Interplay Entertainment Corp., a Delaware corporation ("Corporation"), hereby certifies that the following is a true, full and correct copy of the resolutions adopted by the Corporation by unanimous written consent in lieu of a special meeting of its Board of Directors, and that said resolutions have not been amended or revoked as of the date hereof. RESOLVED, that the Corporation, is hereby authorized to execute, deliver and fully perform that certain document entitled Fourth Amendment to Lease ("Amendment") by and between the Corporation and Arden Realty Finance IV, L.L.C., a Delaware limited liability company, for the lease of space at Von Karman Corporate Center, Irvine, California. RESOLVED FURTHER, that the Corporation is hereby authorized and directed to make, execute and deliver any and all, consents, certificates, documents, instruments, amendments, confirmations, guarantees, papers or writings as may be required in connection with or in furtherance of the Amendment (collectively with the Amendment, the "Documents") or any transactions described therein, and to do any and all other acts necessary or desirable to effectuate the foregoing resolution. RESOLVED FURTHER, that the following officers acting together: _______________ as _____________ and ____________ as _______________ are authorized to execute and deliver the Documents on behalf of the Corporation, together with any other documents and/or instruments evidencing or ancillary to the Documents, and in such forms and on such terms as such officer(s) shall approve, the execution thereof to be conclusive evidence of such approval and to execute and deliver on behalf of the Corporation all other documents necessary to effectuate said transaction in conformance with these resolutions. Date: _____________, 199_ _______________________________________ __________________, Corporate Secretary
Print Name. Signature: Title: Date: SWIFT Contract No.
Print Name. Email Address: Signature of Patient/Parent/Guardian: Please return to your SMG Physician Office or Mail to: HIMS Manager – 000 Xxxxxx Xxxxxx, Xxx Xxxxxxxxxx, XX 00000 Name: Date of Birth: Date: Summit Medical Group is participating in the U.S. Department of Health and Human Services’ "Meaningful Use" program in order to provide better patient care. This program will lead to improved electronic communications and a more complete medical record for our patients. As part of this program, we are required to collect patient information such as race, ethnicity and primary language. If you prefer not to share this information, please feel free to choose the option “I Prefer Not to Report”. Please choose one from each section. Race*: Ethnicity*: □ American Indian or Alaska Native □ Hispanic or Latino □ Asian □ Not Hispanic or Latino □ Black or African American □ I Prefer Not to Report □ Native Hawaiian or Other Pacific Islander □ White □ Unknown or Other □ I Prefer Not to Report Primary Language: □ English □ German □ Spanish □ Italian □ Portuguese □ Polish □ French □ Other Language □ I Prefer Not to Report *The choices of Race and Ethnicity are consistent with choices used in US Census surveys. See page 2 for the US government’s definitions of Race and Ethnicity. Summit Medical Group will soon offer our patients online access to certain portions of their personal health records through a “patient portal”. In addition, we will also soon provide a secure, HIPAA/HITECH compliant, electronic means for communicating with your physician and health care providers. If you are interested in participating, please provide us with your email address so we may alert you when this new patient portal is available. Your email address will not be shared with any entity outside the Summit Medical Group. There is no charge for such participation and participation is entirely optional. Email address: Definitions of Race and Ethnicity as defined by the US Government: American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American. A person having origins in any of the black...
Print Name. Sign: Date: Space: Payment: $ XX Xxxx CK#
Print Name. Address: Card Number: Date: Time: Signature:
Print Name. School/Department: _________________ Date of desired absence: ___________________ I understand that I may purchase 2 days a year at $65 PER DAY, the cost will be deducted from my paycheck. Employee Signature: Date request submitted: Principal/Supervisor: Date approved: An employee who does not turn in an approved form for any extra personal leave taken, or who has already taken their Extra Personal Leave allotment will be charged Loss of Pay at their normal daily rate. Application for Recertification Credit Reimbursement Guidelines:
Print Name. Title: Address: Telephone #: Fascimile #: E-mail Address: (IF CORPORATION OR LIMITED LIABILITY COMPANY SELLER) ACKNOWLEDGEMENT OF RECEIPT OF XXXXXXX MONEY BY BROKER OR BROKER’S AFFILIATED LICENSEE: Weeks Auction Group, Inc. [GA R.E. Lic. #75323] By: As its: GA R.E. Lic. # Date: Exhibit “A” Tract 1: All that tract or parcel of land situate, lying and being in the Southwest Section of the City of Quitman, Brooks County, Georgia, and being a part of Block No. 2, and more particularly described as follows: Beginning at the northeast corner of said block at the southwest corner of the intersection of West Forsyth Street with South Court Street; and running thence south along the west margin of South Court Street 210 feet to the north margin of West Xxxxxxx Street; thence west along the north margin of West Xxxxxxx Street 210 feet to the east margin of South Madison Street; thence north along the east margin of South Madison Street 135 feet to a point; thence east 68 feet to a point; thence north 50 feet to a point; thence east 75 feet to a point; thence north 25 feet to the south margin of West Forsyth Street; thence east 67 feet along the south margin of West Forsyth Street to the Point of Beginning; and bounded on the north by lands of the City of Quitman and West Forsyth Street; on the east by South Court Street; on the south by West Xxxxxxx Street; and on the west by South Madison Street and lands of City of Quitman. Said property is the same as that described in a Warranty Deed from Brooks County Investment Company to X. X. Xxxxxx, et al, dated December 30, 1970, and recorded in Deed Book 105, page 475, of the Deed Records of Brooks County, Georgia. Tract 2: Part of Block No.16 in the Southeast Section of the City of Quitman, Brooks County, Georgia, and more particularly described as follows: Beginning at a point on the east line of said block a distance of 78 feet south of the northeast corner of said block, running thence south 50 feet, thence west 90 feet, thence north 50 feet, thence east 90 feet to the point of beginning; and said land is bounded on the north by lands of General Telephone Company, on the east by South Washington Street, on the south by lands of X. X. Xxxxxxxxx, and on the west by an alley. Also, part of Block No.16 in the Southeast Section of the City of Quitman, Brooks County, Georgia, and described as follows: Beginning at a point on the east line of said block a distance of 128 feet south of the northeast corner of said block, and ...