Address City State Zip Sample Clauses

Address City State Zip. Home Phone Cell Phone Preferred email 1 Family Member Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method * (See Appendix C for Card Details) Yearly (Credit/Debit Card) Monthly (Credit/Debit Card) Monthly (Credit/Debit Card) *All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in Siskiyou Vital Medicine LLC Medical Agreement Form. I further certify that I have received a copy of this form. Date & Time (mm/dd/yyyy hhmm) Signature Fee Itemization Services for services provided by Siskiyou Vital Medicine: Family Plan $220* per month Includes 2 adults plus 1 youth (Additional $30 per youth (Birth to 17)) Individual Plan $100* per month (Includes 1 adult) Youth $ 50* per month Includes on 1 youth (Birth to 17) (one adult membership required) Personalized Plan. Includes # adult(s). # youth(s) *Plans paid by employers may be at a rate other than as published above. Payment Method: Full Name on Card Credit Card #
Sample 1
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Address City State Zip. 0000 Xxxxx Xxxxxxx Xxxxxxx Texas 77036 0000 Xxxxx 00xx Xxxxxx XxXxxxx Xxxxx 00000 0000 Xxxx Xxxx Xxxx. #0000 & #0000 Xxxxxxxx Xxxxx 00000 0000 Xxx Xxxxxxx Xxxx Xxxxxx Xxxxx 00000 000 Xxxxxxxx Xxxxx Lafayette Louisiana 70506 Schedule 7.3 to Amended and Restated Loan and Security Agreement Real Estate 1 SCHEDULE 8.5 to Amended and Restated Loan and Security Agreement DEPOSIT ACCOUNTS Conn Appliances, Inc. Depository Bank Type of Account BANK OF AMERICA Store Deposit Account BANK OF AMERICA Letter of Credit Deposit Account BANK OF AMERICA LC Disbursement Account CAPITALONE Controlled Disbursement Account CAPITALONE General Operating Account CAPITALONE Payroll Account CAPITALONE Payment Center Account CAPITALONE Credit Card Settlement Account CAPITALONE Louisiana Store Depository Account COMMUNITY BANK OF TEXAS Store Deposit Account JPMORGAN CHASE Depository Account JPMORGAN CHASE General Operating Account SUNTRUST General Corporate Account BBVA COMPASS BANK Store Deposit Account XXXXX FARGO BANK Store Deposit Account WOODFOREST Store Deposit Account Conn Credit Corporation, Inc. NONE. Conn Credit I, LP NONE. Schedule 8.5 to Amended and Restated Loan and Security Agreement Deposit Accounts 1 SCHEDULE 8.6.1 to Amended and Restated Loan and Security Agreement CREDIT CARD AGREEMENTS
Sample 1
Address City State Zip. Phone E-mail Fax Official California Fishing Passport Program Educational Partners agree to abide by the following guidelines, requirements and ethical fishing standards: • Provide California Fishing Passports free of charge to anglers who possess a valid annual California fishing license, and to children under the age of 16, upon request • Provide California Finfish and Shellfish Identification Books free of charge (at your discretion). No money/compensation may be collected for the books. • Prior to stamping Fishing Passports, confirm each fish species or witness signature • Educate fellow anglers about the California Fishing Passport program • Educate fellow anglers regarding ethical fishing practices and standards With this approved and signed document, the California Department of Fish and Game (DFG) agrees to provide official Educational Partners the opportunity to obtain the following items:
Sample 1

Related to Address City State Zip

  • Payment Address All payments required by this Settlement Agreement shall be delivered to the following address: The Chanler Group Attn: Proposition 65 Controller 0000 Xxxxx Xxxxxx Xxxxxx Xxxxx, Suite 214 Berkeley, CA 94710

  • Email Address (For delivery of Documents to Seller) (For delivery of Documents to Buyer)

  • Change in Address for Notices Each of the Grantors, the Administrative Agent and the Lenders may change the address for service of notice upon it by a notice in writing to the other parties.

  • Address Changes The parties agree to promptly notify each other of any change of address.

  • Name or Address Changes It is your responsibility to notify the Credit Union of a change in mailing or physical address, change of email address or change of name. The Credit Union is only required to attempt to communicate with you only at the most recent address you have provided to the Credit Union. If the Credit Union attempts to locate you, the Credit Union may impose a service fee as set forth on the “Schedule of Fees and Charges.”

  • Address Change Client shall notify Sapphire Check if Client changes its name or address.

  • WITNESS ADDRESS DATE ............................................................................................................................ SIGNED BY TENANT/JOINT TENANT ........................................................................

  • Notice Address Subject to Section 4.1.4, all notices and other communications by or to a party hereto shall be in writing and shall be given to any Borrower, at Borrower Agent’s address shown on the signature pages hereof, and to any other Person at its address shown on the signature pages hereof (or, in the case of a Person who becomes a Lender after the Closing Date, at the address shown on its Assignment and Acceptance), or at such other address as a party may hereafter specify by notice in accordance with this Section 14.3. Each such notice or other communication shall be effective only (a) if given by facsimile transmission, when transmitted to the applicable facsimile number, if confirmation of receipt is received; (b) if given by mail, three Business Days after deposit in the U.S. mail, with first-class postage pre-paid, addressed to the applicable address; or (c) if given by personal delivery, when duly delivered to the notice address with receipt acknowledged. Notwithstanding the foregoing, no notice to Agent pursuant to Section 2.1.4, 2.3, 3.1.2, 4.1.1 or 5.3.3 shall be effective until actually received by the individual to whose attention at Agent such notice is required to be sent. Any written notice or other communication that is not sent in conformity with the foregoing provisions shall nevertheless be effective on the date actually received by the noticed party. Any notice received by Borrower Agent shall be deemed received by all Borrowers.

  • NOTIFICATION OF ADDRESS CHANGE You will notify Us promptly in writing with Your signature if You move or otherwise have a change of address. In the event We are unable to locate You, You agree to pay all fees associated with maintaining an invalid address in Our records and any costs and locator fees incurred in Our locating efforts.

  • Notification of address and fax number Promptly upon receipt of notification of an address and fax number or change of address or fax number pursuant to Clause 31.2 (Addresses) or changing its own address or fax number, the Agent shall notify the other Parties.

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