ACKNOWLEDGEMENT FORM. The Old Colony Regional Vocational Technical High School is registered under the provisions of M.G.L. c. 6, § 172 to receive XXXX for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licenses, and applicants for the rental or lease of housing. As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a XXXX check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to Old Colony Regional Vocational Technical High School to submit a XXXX check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing Old Colony Regional Vocational Technical High School with written notice of my intent to withdraw consent to a XXXX check. Your hiring is subject to a National Background and XXXX check, satisfactory to the employer, and is a condition of hiring or continuation of employment prior to the receipt of the above referenced criminal checks.
ACKNOWLEDGEMENT FORM. The _Cobb County assures that no person shall on the grounds or race, color, national origin or sex as provided by Title VI of the Civil Rights Act of 1964, and the Civil Rights Restoration Act of 1987 be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any City or County sponsored program or activity. The _Cobb County_ assures that every effort will be made to ensure nondiscrimination in all of its programs or activities, whether those programs are federally funded or not. Assurance of compliance therefore falls under the proper authority of the City Council or the County Board of Commissioners. The Title VI Coordinator or Liaison is authorized to ensure compliance with provisions of this policy and with the Law, including the requirements of 23 Code of Federal Regulations (CFR) 200 and 49 CFR 21. Xxxx X. Xxxxx – Chairwoman Date Citations: Title VI of the Civil Rights Act of 1964; 42 USC 2000d to 2000d-4;42 USC 4601to 4655;23 USC 109(h); 23 USC 324; DOT Order 1050.2; EO 12250; EO 12898; 28CFR 50.3 Other Nondiscrimination Authorities Expanded the range and scope of Title VI coverage and applicability The 1970 Uniform Act (42 USC 4601) Section 504 of the 1973 Rehabilitation Act (29 USC 790) The 1973 Federal-aid Highway Act (23 USC 324) The 1975 Age Discrimination Act (42 USC 6101) Implementing Regulations (49 CFR 21& 23 CFR 200) Executive Order 12898 on Environmental Justice (EJ) Executive Order 13166 on Limited English Proficiency (LEP) NOTICE TO SPONSOR/LOCAL GOVERNMENT COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 During the performance of this contract, the SPONSOR/ LOCAL GOVERNMENT, for itself, its assignees, and successors in interest (hereinafter referred to as the "SPONSOR"), agree as follows:
ACKNOWLEDGEMENT FORM. I am the parent or legal guardian of the Student. I consent to my child’s use of the school issued Google Chromebook, and other District approved apps at school and/or at home, and agree to the foregoing terms and conditions applicable to such use. In addition, I understand and acknowledge that while my child is participating in classroom lessons remotely, he/she will be expected to act in accordance with the District’s Code of Conduct and may be disciplined in the event of an infraction pursuant to the provisions of the Code of Conduct. Student name: Student ID Number: School: Teacher: Homeroom: Parent name: Parent signature: Date:
ACKNOWLEDGEMENT FORM. This signed form must be provided prior to participating in any league sponsored events including practices ❖ I/ we agree that the below criteria must be met prior to attending any HLL sponsored events as on field participants or spectators: • Show no signs or symptoms of COVID-19 as defined by the CDC xxxxx://xxx.xxx.xxx/coronavirus/2019-ncov/symptoms- testing/symptoms.html • Have not been asked to self-isolate or quarantine by their doctor, a local publichealth official, or school nurse. ❖ If the above self-certification cannot be met I / we will voluntarily remove ourselves from participation in all HLL events Parent / Guardian 1: Print: Sign: Parent / Guardian 2: Print: Sign: Player: Print: Sign:
ACKNOWLEDGEMENT FORM. I acknowledge that Denali CRT have reviewed with me on the date below, clients’ Rights and Responsibilities, and Grievance Procedures and I know how to report a problem, complaint, or grievance with the enclosed forms,. Client’s Printed Name Client # Client’s Signature Date Denali CRT Authorized Signature Date Client Privacy Policy Acknowledgement Form I acknowledge that Denali CRT staff have reviewed the Denali CRT LLC. Notice of Privacy Practices (NPP) with me on the date below: Client’s Printed Name Client # Client’s Signature Date
ACKNOWLEDGEMENT FORM. The attached Vendor Code of Conduct sets forth the principles required by the Regional Municipality of Halton (“the Region”) of all Vendors who supply goods and services to the Region when conducting business with the Region. By signing this Acknowledgement, the undersigned Vendor agrees to abide by the Vendor Code of Conduct and also agree toensure its employees, officers, agents, representatives, and subcontractors are also made aware of and comply with it.
ACKNOWLEDGEMENT FORM. I acknowledge that I have been given a copy of the Employee Proprietary Information and Inventions Agreement, that I have read it, and that I understand its terms and procedures. Furthermore, I agree to abide by it and understand that if NewLink determines my conduct warrants it, I may be subject to discipline for breaches hereof, up to and including the immediate termination of my employment. Xxxx Xxxxxx Employee’s Name (Please Print) /s/Xxxx Xxxxxx Employee’s Signature 9/24/2019 Date EXHIBIT B RELEASE [To be signed on or within twenty-one (21) days after the Separation Date] My employment with NewLink Genetics Corporation (the “Company”) ended in all capacities on ___________ (the “Separation Date”). I hereby confirm that I have been paid all compensation owed to me by the Company for all hours worked; I have received all the leave and leave benefits and protections for which I was eligible, pursuant to the Company’s policies, applicable law, or otherwise; and I have not suffered any on-the-job injury or illness for which I have not already filed a workers’ compensation claim. If I choose to enter into this Release and allow it to become effective by its terms, the Company will provide me with certain severance benefits pursuant to the terms of the Employment Agreement between me and the Company dated _____, 2019 (the “Agreement”). I understand that I am not entitled to such severance benefits unless I return this fully-executed Release to the Company within twenty-one (21) days after the Separation Date and allow this Release to become fully effective and non-revocable by its terms. (Capitalized terms used but not defined in this Release shall have the meaning ascribed to them in the Agreement.) In exchange for the severance benefits to which I would not otherwise be entitled, I hereby generally and completely release the Company and its directors, officers, employees, shareholders, partners, agents, attorneys, predecessors, successors, parent and subsidiary entities, insurers, affiliates, and assigns (collectively, the “Released Parties”) from any and all claims, liabilities and obligations, both known and unknown, arising from or in any way related to events, acts, conduct, or omissions occurring prior to or at the time that I sign this Release, including but not limited to claims arising from or in any way related to my employment with the Company or the termination of that employment (collectively, the “Released Claims”). By way of example, the Rele...
ACKNOWLEDGEMENT FORM. When each Delivered Product is installed and is, in all material respects, up and running in accordance with its Functional Specifications, Customer hereby agrees to promptly sign an acknowledgement form confirming the foregoing. In order to facilitate Customer’s signature on an acknowledgement form, Omnicell agrees to conduct a demonstration showing that the Delivered Products function as set forth in the previous sentence. If the Customer has not signed the acknowledgement form within ten (10) days of a successful demonstration, then the Delivered Products shall be deemed accepted by Customer per the language of the acknowledgement form.
ACKNOWLEDGEMENT FORM. (a) ACSA requires a Proponent confirm whether or not it intends to submit a Proposal by signing and submitting to ACSA the Acknowledgement included within Exhibit A to this RFP (the "Acknowledgement").
ACKNOWLEDGEMENT FORM. The WIC local agency is responsible for educating WIC employees hired by their local agency about the WIC Program rules, policies and procedures. All employees must sign the Illinois WIC Employee Confidentiality and Compliance Agreement Signature Form in the presence of the Local Agency WIC Coordinator, Clinic Supervisor, or local agency designee. A copy of the signed agreement must be retained and available for review by the department. Addendum – Employee Compliance Report Addendum - Illinois WIC Employee Confidentiality and Compliance Agreement Signature Form Employee Violation Sanction Action Enrolling one’s self into the WIC program.Issuing benefits to self. • Submission of Employee Compliance Report to Department (WIC Central Office). • Immediate termination of all WIC roles. Altering food benefits.Attempted or actual use of altered food benefits. Sale of or attempt to sell WIC food benefits verbally, in print, or online. Falsification of data for eligibility, i.e., providing false information to receive WIC benefits for self or others. Creation of records for fictitious clients. Disclosing confidential information regarding participants to any non-WIC official or the public at-large. Failure to report a conflict of interest as outlined in the IL WIC Local Agency WIC Employee Compliance policy. • Submission of Employee Compliance Report to Department (WIC Central Office). Enrollment, certification or issuance of food benefits to one’s relative or close friend or to a participant whom the employee serves as proxy without WIC Coordinator approval. Unprofessional or unfair treatment, including verbal abuse, towards WIC applicants, participants, other clinic staff or vendors. Discrimination toward WIC applicants, participants, other WIC staff and vendors due to race, color, national origin, etc. • Submission of Employee Compliance Report to Department (WIC Central Office). **Civil Rights Complaints should refer to IL WIC PPM A-6.
