Attestation Form. As indicated above, I have elected to use shares of Pacific Financial Corporation common stock that I already own to pay the Aggregate Purchase Price of the Option (and withholding taxes, if applicable). I attest to the ownership of the shares represented by the certificate(s) listed below or to the beneficial ownership of the shares held in the name of my broker, as indicated in the attached copy of my brokerage statement. I will be deemed to have delivered such shares to Pacific in connection with the exercise of my Option. I understand that, because I (and any joint owner) will retain ownership of the shares (the "Payment Shares") deemed delivered to pay the Aggregate Purchase Price (and withholding taxes, if applicable), the number of shares to be issued to me upon exercise of my Option will be reduced by the number of Payment Shares. I represent that I have full power to deliver and convey certificates representing the Payment Shares to Pacific and by such delivery and conveyance could have caused Pacific to become sole owner of the Payment Shares. The joint owner of the Payment Shares, if any, by signing this Form, consents to these representations and to the exercise of the Option by this attestation. I certify that the Payment Shares have not been used or acquired in a stock-for-stock exercise of any option within the six months preceding the exercise of this Option. I also certify that, if the Payment Shares were acquired by me upon exercise of a stock option or as restricted shares, (a) I have held the Payment Shares for at least six months, and (b) any Payment Shares originally issued to me as restricted shares are now fully vested. List certificate(s) and number of shares covered, or attach a copy of your brokerage statement: Common Stock Certificate Number Number of Shares Covered Date: Print Name of Option Holder: Signature of Option Holder: Print Name of Joint Owner: Signature of Joint Owner: If you are attaching a copy of your brokerage statement, you must have your securities broker complete the following: The undersigned hereby certifies that the foregoing attestation is correct. Name of Brokerage Firm Date: By: Telephone No.: Print Name of Signing Broker
Attestation Form. If Consultant is an individual or sole proprietor, Consultant agrees to complete the United States Citizenship Attestation Form as provided by City and attach it to the Agreement.
Attestation Form. I hereby request that the District of Columbia Addiction Professional Consortium Certification Board (DCAPC) grant the certificate issued to me based on the following assurances and documentation: • I hereby certify that the information given herein is true and complete to the best of my knowledge and belief. • I attest to the fact that all certificates enclosed are mine and are for trainings that I personally attended. • I attest to the fact that the description of my job that is enclosed is an accurate representation of my work in the field of substance abuse treatment. Allegations of ethical misconduct reported to DCAPC before, during or after application for certification is made will be investigated by DCAPC and could result in the nullification of the application or denial or revocation of the certification. Initial: Date: By signing below, I agree to abide by the Ethics, Ethical Procedure, Assurance and Release and Attestation as described in this document. Signature: Date: Please print below the exact way you wish your name to appear on your certificate. Print Full Name: Notary Public
Attestation Form. All students who are not included on the student list must fill out this Attestation Form stating they are a Training Partnership Student. Network: Date: xx/xx/ xxxx Class and Module Number: Instructor Full Name: Student Full Name: Training ID number: Student Last 4 SSN: Employer: Student Phone: (Include area code) I understand that my name does not appear on the roster for this class. If my instructor says there is room in the class, I may choose to stay but understand that I may not receive credit and/or may not be paid for my time. Student Name: Student Signature: APPENDIX 9 Incident Reporting Form An Incident is an unusual event that occurs surrounding instruction delivery and disrupts the class delivery process. Reported incidents should clearly outline all details relevant to the incident, the events contributing to the incident, the actions taken by the network provider in response to the incident, and if the incident was resolved or if additional actions are required. A Complaint is a statement that a situation is unsatisfactory or unacceptable. Learners with complaints should be encouraged to contact the MRC via phone at l-866-371-3200 or via email at XXX@xxxx000.xxx. Instructors with complaints should submit an Incident Report to the network PPC to escalate the issue to the Training Partnership. Example Attached This policy is subject to change Incident Reporting Form The SEIU Healthcare NW Training Partnership is committed to ensuring that students, faculty, administrators, and staff spend their days in a safe and healthy environment. Together, we will make every effort to protect you r identity and the confidentiality of this statement. However, we may need to contact you for further information as we investigate the incident. We are asking everyone to use this confidential form to report any concerns, incidents or potential incidents relating to: Personal Injury/sickness Disruptive /Inappropriate behavior Violence Disparagement of religion(s) or (including harm to self or others) engagement of religious activities Engagement of lobbying or Bullying political activity drugs, or weapons Sexual harassment Other Name of Reporter: Are you: (circle one) Staff Instructor Student Student’s Employee: Date of Incident: Time of Incident: Place of Incident: (classroom, other) Person(s) directly involved in incident: Witness to Incident: Description Of Incident (Please provide specific details below and if necessary you may attach another sheet): Email: Ph...
Attestation Form. This form must be returned annually to FWC by April 1 to satisfy the requirements under the Governor’s Executive Order Number 20-44, published February 20, 2020. Your attestation is needed for the following information: Legal Name of Organization: IRS Issued Tax Id/DUNS Number: Type of Organization: Non-Profit For-Profit Educational Institution Local Municipality Other Service Location for Organization: (city), (county)
Attestation Form. School shall complete an Attestation Form for all Program Participant pursuant to Exhibit C, attached hereto, and incorporated herein by reference. Completed form will be sent to the Hospital Authority.
Attestation Form. 8. Sales Tax Exemption Form 13 The herein above mentioned Contract Documents form this Contract and are a part of the Contract as if hereto attached. Said documents which are not attached to this document may be viewed at: xxxxxxx.xx.xxx - Keyword: Bid - Awarded or Closed bids. This Contract contains the complete and entire Contract between the parties and may not be altered or amended except in writing executed, making specific references to this Contract, by a duly authorized officer of the Contractor and by a duly authorized official of the County. The Contractor and the Owners hereby agree that all the terms and conditions of this Contract shall be binding upon themselves, and their heirs, administrators, executors, legal and personal representatives, successors, and assigns.
Attestation Form. If Engineer is an individual or sole proprietor, Engineer agrees to complete the United States Citizenship Attestation Form and attach it to the Agreement.
Attestation Form. Contemporaneously with the delivery of each financial statement required by Sections 7.5(a) and (b) above, an attestation form substantially in the form of Exhibit "B" attached hereto and made a part hereof, signed by an authorized officer of Borrower and attesting to the truthfulness and accuracy of the information set forth in such financial statements.
