CHECK ALL THAT APPLY. During the past thirty (30) days, I have taken the following medication(s) prescribed to me by a physician: Name of Medication Prescribing Physician Date Last Taken During the past thirty (30) days, I have taken the following nonprescription medications (cough medicine, cold tablets, aspirin, diet medication, nutritional supplements, etc.)
CHECK ALL THAT APPLY. ¨ The undersigned sold the shares identified above pursuant to a registration statement filed under the Securities Act of 1933 (the “Securities Act”). ¨ The undersigned sold the shares identified above pursuant to Rule 144 under the Securities Act. Terms used herein without definition shall have the meanings ascribed to them in the Stockholders Agreement. The undersigned understands and acknowledges that the Company will rely upon this Notice of Proposed Transfer/Affiliate Status in connection with its rights and obligations under the Stockholders Agreement. Date: Holder’s Name:
CHECK ALL THAT APPLY. ¨ The shares identified above were transferred to a Permitted Affiliate of the Investor. ¨ The shares identified above were transferred to an Affiliate of the Investor. ¨ The shares identified above were transferred to a Person which is not an Affiliate of the Investor in compliance with Section 4.1 or Section 4.2 of the Stockholders Agreement. ¨ The undersigned is currently an Affiliate of the Investor. ¨ The undersigned is providing this Notice to notify the Company that it is no longer a Permitted Affiliate of the Investor. (If this box is checked, please provide the information requested below.) The undersigned lost the status of a Permitted Affiliate of the Investor on (enter date) ¨ The undersigned is providing this Notice to notify the Company that it is no longer an Affiliate of the Investor. (If this box is checked, please provide the information requested below.) The undersigned lost the status of an Affiliate of the Investor on (enter date)
CHECK ALL THAT APPLY. It is prescribed to □ Reduce Pain □ Increase Range of Motion (ROM) □ Reduce Muscle Spasm □ Post-Operative/Surgical Procedure □ Post- Operative/Post Procedural Pain Control and Edema □ Other (specify below): □ Reduce Reliance on Narcotics/Analgesics □ Reduce Edema/Swelling To be signed and completed by patient upon receipt of product(s): Dear Patient: PLEASE READ THIS STATEMENT AND SIGN BELOW Pro Med Inc. is not financially affiliated with the medical group or physician. Your physician must prescribe all services and/or products provided by Pro Med Inc. I here-by authorize Pro Med Inc. to furnish this service/product and to provide my insurance company with any information requested for payment. I also instruct my insurance company to pay Pro Med Inc. directly for these service/products. I understand that all costs for service/products not paid for by my insurance company for any reason will become my personal financial responsibility. Assignment of benefits does not guarantee that my insurance company will pay for these service/products. I have received the above referenced product/services from Pro Med Inc., and have been instructed in the care and use of the product. I understand that all medical devices are not returnable for any reason other than material defect. MEDICARE AND OTHER INSURANCE COMPANIES will only pay for services/products that they determine to be reasonable and necessary under section 1862(a)(1) of the Medicare regulations. It Medicare or other insurance company determines that the product/service, although otherwise a covered product/service, is not reasonable or necessary under Medicare or other Insurance company standards. Medicare or other insurance company may deny payment for these service/products. Pro Med Inc. cannot be certain that Medicare or other Insurance company will view your doctor’s request for the above listed product/service to be reasonable or necessary or that your doctor’s supporting documentation will be accepted by Medicare or other insurance company. I have been advised of my privacy rights pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. □ Check here if you would like to receive electrodes supplies for 24 month
CHECK ALL THAT APPLY. (a) The undersigned is an individual with a net worth, or a joint net worth together with his or her spouse, in excess of $1,000,000. (In calculating net worth, you must exclude the value of your primary residence. You may include equity in other personal property and real estate, cash, short-term investments, stock and securities. Equity in personal property and real estate should be based on the fair market value of such property minus debt secured by such property.) ____ (b) The undersigned is an individual that had an individual income in excess of $200,000 in each of the prior two years (2009 and 2008) and reasonably expects an income in excess of $200,000 in the current year (2010); or ____ (c) The undersigned is an individual that had with his/her spouse joint income in excess of $300,000 in each of the prior two years (2009 and 2008) and reasonably expects joint income in excess of $300,000 in the current year (2010). ____ (d) The undersigned is a director, president, vice president in charge of a principal business unit, division or function (such as sales, administration or finance); any other officer who performs a policy making function, or any other person who performs similar policy making functions for Vision Technologies, Inc., a Delaware corporation. ____ (e) The undersigned, either alone or with the undersigned's professional advisor or advisors, has such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of acquiring the Shares, and is able to bear the economic risk of the investment in the Shares, including a complete loss of the investment. ____ (f) None of the above.
CHECK ALL THAT APPLY. All Tier 1 items and: ☐Local area is on track to meet priority of service requirements for the Adult program; ☐Local area is enrolling participants in Work-based Training (On the Job Training, Apprenticeships, Internships, Work Experiences, etc.) as part of the plan; and ☐Local area is conducting outreach activities to Dislocated Workers, such as participation in Rapid Response or Reemployment Services and Eligibility Assessment (RESEA), across all eligibility categories applicable to the local area and to those with barriers to employment. TIER 3 (
CHECK ALL THAT APPLY. All Tier 1 and 2 items and: ☐Local area has a documented, significant need to transfer funds; ☐Local area has collaboration with Partner Agencies demonstrated by co-enrollments and leveraging of multiple funding streams and program referrals; and ☐Local Area has met or is on track to meet its goals for discretionary grants that serve adults and dislocated workers.
CHECK ALL THAT APPLY. (a) The undersigned is an individual with a net worth, or a joint net worth together with his or her spouse, in excess of $1,000,000. (In calculating net worth, you may include equity in personal property and real estate, including your principal residence, cash, short-term investments, stock and securities. Equity in personal property and real estate should be based on the fair market value of such property minus debt secured by such property.)
CHECK ALL THAT APPLY. Description of service attached. A full position /project description should be attached. List of group participants attached - required if this is a group agreement. Valid driver’s license verified - Check if applicable. Required if volunteer will be driving a government vehicle. International volunteers will need to check with the individual state where their service will be performed, to determine what additional licensing may be required to operate a vehicle. Each situation may be different. Job Hazard Analysis: Recommended Page 2 of OF301a: 26-32. Parental Consent for Volunteer Under Age 18: Name of parent or legal guardian is required including complete contact information. For Group agreements, the Group leader’s name and contact information must be on page one. Parent or Guardian prints name of youth (printed) in box #31 and signs and dates box #32. The parent/guardian should also sign section 34.
CHECK ALL THAT APPLY. Pre Tax New Enrollment New Enrollees must enroll with TIAA online. ** Please see below for more details. After Tax (Xxxx) Restart Contribution Change Contribution Amount Stop Contribution This agreement shall be legally binding and irrevocable to each of the parties hereto while employment continues. I understand this election will continue until I submit another agreement form to change or discontinue the contributions from my paycheck. I also state that I have read, understand, and accept the terms highlighted on the 403(b) Plan Information page. The responsibility for contribution calculations lies with the employee and their financial counselor or investor service representative. The amounts indicated above must not exceed the employee’s statutory exclusion allowance under section 403(b) or the limitations of Section 402(g) or Section 415(c) of the Internal Revenue Code. Employee’s Signature Date Please send or scan this form with your original signature to Retirement Savings Plans, 0000 Xxxxx Xxxxxx Xxxx., Xxxxx 000, Xxxxxxxxxxxx, XX 00000. Questions? XxxxxxxxxxXxxxxxxxx@XXXX.XXXXX.XXX OR Fax to 0-000-000-0000 **FOR QUESTIONS contact TIAA’S enrollment hotline at 000-000-0000 (Plan #150392) _ Administrative Use: Initials Date
