AGREEMENT SIGNATURES. This Agreement, having been approved on the 23rd day of April 2002 by Anchorage Municipal Assembly Resolution No. (“AR”) 2002 - 119, the parties to this Agreement hereby enter into this Agreement effective as of the 1st day of October, 2002. MUNICIPALITY of ANCHORAGE STATE OF ALASKA By: Xxxxxx X. Xxxxxx, Mayor By: Xxxx Xxxxxxx, Governor
AGREEMENT SIGNATURES. The parties agree to the terms and conditions of this Service Agreement. Signature of Participant’s representative Name of Participant’s representative Date Signature of authorised person from provider: Name of authorised person from provider: Date
AGREEMENT SIGNATURES. By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signєd by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signєd by Xxxxxx ™єsponsiblє: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: Name: SignaĒurє on bєhalf of FighĒing Chancє: Signature of Representative: Date: 24.11.2023 Name: Xxxx Xxxxx Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invo...
AGREEMENT SIGNATURES. In Witness whereof, the Employer and the Union have caused this Agreement to be executed by their authorized representatives. UNIVERSITY OF NEW MEXICO HOSPITALS Xxxxxxx XxXxxxxx Date CEO, UNM Hospitals Health System Chief Operations Officer COMMUNICATIONS WORKERS OF AMERICA Xxxxx Xxxxx Date CWA Representative Union Bargaining Committee Members: Xxxxxx Xxxxx, President Local 7076 Appendix A Subject to Article 1, the parties recognize that the following job titles employed at ASAP, CPC, CTH, UNMPC and affiliated clinics, including YCHC and M&FP, are represented under the provisions of this Agreement. CWA - ADMITTING REPRESENTATIVE CWA - TECH MENTAL HEALTH III CWA - AIDE FOOD SVC CWA - TECH NURSING CWA - AIDE NURSE CWA - TECH ORTHO I CWA - AIDE SOCIAL WORK CWA - TECH ORTHO II CWA - ASSOC MENTAL HEALTH CWA - TECH ORTHO III CWA - ASST CLINICAL CWA - TECH PATIENT CARE CWA - ASST MEDICAL CWA - TECH PHARMACY I CWA - ASST MEDICAL CERTIFIED CWA - TECH PHARMACY II CWA - CLERK CLINICAL SPEC CWA - TECH QUALITY CWA - CLERK DC & CHARGE ENTRY CWA - TECH REHAB SVCS CWA - CLERK I CWA - TRANSCRIPTIONIST SR CWA - CLERK III CWA - CLERK MEDICAL RECORDS SR CWA - CLERK OUTPT CWA - CODER I CWA - COOK I CWA - COOK II CWA - COORD MED RECRD RESEARCH CWA - COORD PATIENT CARE CWA - COORD PCMH CWA - GARDENER CWA - HOUSEKEEPER CWA - MAINT SPEC CPO VI CWA - MAINT SPEC ELECTRICIAN V CWA - MAINT SPEC II CWA - MAINT SPEC III CWA - MAINT SPEC PAINTER IV CWA - MAINT SPEC UTILITIES CWA - MHA DRIVER CWA - MHT I DRIVER CWA - MHT II DRIVER CWA - REP PATIENT SERVICES CWA - SPEC MEDICAL RECORDS CWA - SPEC REGISTRATION & ELIGIBILITY CWA - TECH DIETETIC CWA - TECH HEALTH INFO MGMT (HIM) CWA - TECH HEALTH INFO MGMT II CWA - TECH MENTAL HEALTH I CWA - TECH MENTAL HEALTH II Appendix B AUTHORIZATION FOR DEDUCTION OF UNION DUES COMMUNICATIONS WORKERS OF AMERICA Last Name First Name and Initial Employee Number Home Mailing Address Social Security Number Job Title Work Location I hereby authorize the Employer to deduct from the compensation due me on the first two
AGREEMENT SIGNATURES. The Parties, through their respective duly authorized signatories, are signing this Grant Agreement on the date set forth above. GRANTEE: «GRANTEE_NAME» «Agency_Street_Address» «Agency_City_State_Zip» Agreed & Accepted: PRINT NAME and TITLE of AUTHORIZED SIGNATORY SIGNATURE PRINT NAME and TITLE of AUTHORIZED SIGNATORY SIGNATURE NOTE:IF GRANTEE IS A CORPORATION, TWO SIGNATURES MAY BE REQUIRED AND COMMISSION: LOS ANGELES COUNTY CHILDREN AND FAMILIES FIRST - PROPOSITION 10 COMMISSION (aka FIRST 5 LA) 000 Xxxxx Xxxxxxx Xxxxxx, Xxxxx 000 Xxx Xxxxxxx, Xxxxxxxxxx 00000 Agreed & Accepted: XXX XXXXXX, EXECUTIVE DIRECTOR Approved as to Form:
AGREEMENT SIGNATURES. By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signed by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signed by Person Responsible: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: SignaĒure on behalf of FighĒing Chance: Signature of Person(s) responsible: Date: Name: Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invoices to: Please see A...
AGREEMENT SIGNATURES. Covered Entity: Wright County, Minnesota Covered Entity Official Authorized Signature: Date: Xxx Xxxxx, Administrator Wright County Business Associate: Dakota Conservators Business Associate Official Authorized Signature: Date: Xxxxxx Xxxxxxxxx, Owner New Challenges Inc d/b/a Dakota Conservators APPENDIX A The Contractor will assure that services rendered hereunder are provided in compliance with all state and federal laws pertaining to the provision of guardianship and/or conservatorship services including but not limited to MN Statute 524.5-101 to 524.5-502, MN Statute 626.557, and MN Statute 245.94 Subd. 2a. Office of the Ombudsman for Mental Health, Mandatory Reporting. Fundamental Requirements The Contractor will fulfill all court related guardianship and/or conservatorship responsibilities and provide all required legal notices to the court and individual for whom they are providing services, including but not limited to: the annual well-being report (guardianship) or annual account of assets (conservatorship) for each client it serves and file it with the court. The Contractor agrees to maintain, at all times during the term of this contract, a process whereby its current and prospective employees and volunteers who will have direct contact with persons served by the program or program services, will consent to a background study for evidence of maltreatment of adults or minors substantiated as required under MN Statute 524.5-118 and 245C.32. Background studies will be supplied to the County and Court upon written request. The Contractor agrees to inform the County of the following, related to it or its employees immediately: any allegation and/or investigation by government agency of fraud or criminal wrongdoing, and concerns that may impact the well-being of the individual being served. The Contractor must petition the Court and receive Court approval for any changes to services to a new provider as well as temporary delegation of guardianship power to another guardian during leaves of absence. The Contractor agrees to communicate all petitions for changes in status to the County. If the status change is approved, the Contractor must ensure new provider has access to all client information and accounts. Anyone entrusted with guardianship/conservatorship responsibilities must comply with the requirements outlined in this Appendix A. The Contractor will accurately and timely report all vulnerable adult and child protection concerns. The Contractor w...
AGREEMENT SIGNATURES. The Parties agree to the terms and conditions of this Service Agreement. PARTICIPANT / REPRESENTATIVE NAME: SIGNATURE: DATE: SERVICE PROVIDER: Empowrd Pty Ltd CONTACT DETAILS: Bec Kolpondinos / 0428 824 665 Xxxxx Xxxxx / 0427 255 172 SIGNATURE:
AGREEMENT SIGNATURES. When executed by LANDLORD and TENANT(S), LANDLORD and TENANT(S) agree that this shall constitute a binding agreement for the Lease of this property. All parties to this Agreement have read and agree to abide by all rules and regulations listed herein. In consideration hereof, the undersigned hereby guarantee the faithful performance of the covenants and conditions of this Lease. By signing this lease you are securing this property for rental during the lease period.
AGREEMENT SIGNATURES. The Parties, through their respective duly authorized signatories, are signing this Grant Agreement on the date set forth above. GRANTEE: «GRANTEE_NAME» «Agency_Street_Address» «Agency_City_State_Zip» Agreed & Accepted: PRINT NAME and TITLE of AUTHORIZED SIGNATORY SIGNATURE PRINT NAME and TITLE of AUTHORIZED SIGNATORY SIGNATURE ANDCOMMISSION: LOS ANGELES COUNTY CHILDREN AND FAMILIES FIRST - PROPOSITION 10 COMMISSION (aka FIRST 5 LA) 000 Xxxxx Xxxxxxx Xxxxxx, Xxxxx 000 Xxx Xxxxxxx, XX 00000 Agreed & Accepted: XXX XXXXXX, EXECUTIVE DIRECTOR Approved as to Form:
