Check one box o I am attaching a cashier’s, personal or certified check, or have arranged for a wire transfer of immediately available funds to the Company, in an amount equal to the Aggregate Exercise Price. o In lieu of paying cash, I have elected to receive such lesser number of shares of Common Stock as determined pursuant to Section 1B(ii) of the attached Warrant. By: Name: Title:
Check one box. ¨ No performance target levels are applicable to this grant of Restricted Shares. ¨ The following performance target levels are applicable to this grant of Restricted Shares. In addition to the continued employment of Participant by (the “Employer”), the lapse of the forfeiture provisions referred to in Section 1 above shall also be conditioned upon the achievement by the Employer and its Subsidiaries, if any, of the following stipulated levels of earnings before interest, taxes, depreciation and amortization (“EBITDA”) for the measurement periods noted below: Measurement Date Measurement Period Percentage of Shares as to which Forfeiture Provisions Lapse EBITDA Target Level1 First anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA 2 Second anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA Third anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA Fourth anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA Fifth anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA 1 In computing EBITDA for periods subsequent to , 20 , the Company shall use actual revenues for the relevant measurement period and the expenses used in determining Base EBITDA.
Check one box. ☒ All travel and meals are included as part of this Contract. No reimbursements shall be made to Contractor. ☐ The University shall reimburse travel and meals in accordance with the Contract and subject to University’s Travel Policy.
Check one box. ☒ All travel and meals are included as part of this Contract. No reimbursements shall be made to Contractor.
Check one box. □ 1 person □ 6 persons □ 2 persons □ 7 persons □ 3 persons □ 8 persons □ 4 persons □ Over 9 persons □ 5 persons Household/Family Income Summary Check one box □ $42,850 or below family income □ $71,400 or below family income □ $106,000 or below family income □ $139,950 or above family income □ Other: Hispanic: Yes / No □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Pacific Islander Ethnicity Check one box □ American Indian/White □ Asian/White □ Black/White □ American Indian/Black □ Other/Multi-Racial I acknowledge that the Tech Lending Library Services are intended for library patrons who do not otherwise haveaccess to the equipment or services sufficient to meet the patron’s educational needs. To the best of my knowledge, the information above is correct and I fully understand that the information provided will be shared with the Library Services special grant reporting purposes, where names and identifiable information will be removed. Signature: Date: Email Address: Library card # Demographic Information (REQUIRED): Cell/Home #: Gender: Male/Female For Staff Completion: Technology Equipment: (Max 3 Devices Per Check-Out) [ ] Chromebook Serial Number Issued: [ ] Mi-Fi (up to 1 device) Serial Number Issued: [ ] Samsung Tablet Serial Number Issued: Device Tag Colors (last 4 digits of serial number) Yellow Green Orange Device Check-Out Date: Device Return Date: Tech Lending Library Borrowing Policy & Agreement Hayward Public Library Borrowing Policy for Long-Term Checkouts • Hayward Public Library’s technology equipment may be checked-out by Hayward residents whom otherwise do not have access to broadband internet or a computing device, who are 18 years and older, and complete this Borrowing Policy & Agreement Form. • A valid Hayward Public Library card number is required. • A borrower must read, understand, and sign this agreement before any technology equipment is checked- out. • The loan period for technology equipment check-out is 12 weeks. After the last day of the loan period, any late or unreturned devices will be disabled and rendered useless after the 2 day grace period. Technology equipment must be returned directly to the Downtown Library’s Account’s Desk. • All equipment and peripherals (boxes, power brick, etc.) must be returned on or before the due date and time indicated.
Check one box. If no box is checked, the Alternate Beneficiary is your Estate. Any balance in my Account not distributed to the above shall be distributed as follows: To my Children who survive me, in equal shares, as provided in No. 2 above To the following Alternate Beneficiary(ies) who survive me* in the indicated percentages: Name Social Security No. Percentage ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % Total __100__ %
Check one box. I do not give permission for my child to access the District’s technology resources. I have read the District’s technology resources policy, associated administrative regulations, and this user agreement. In consideration for the privilege of my child using the District’s technology resources, I hereby release the District, its operators, and any institutions with which it is affiliated from any and all claims and damages of any nature arising from my child’s use of, or inability to use, these resources, including, without limitation, the type of damage identified in the District’s policy and administrative regulations. I understand that my child’s use of the District’s technology resources is not private and that the District may monitor my child’s activity. I understand that the District uses certain cloud-based (online) applications, meaning applications such as Google docs and Skyward that allow authorized individuals to access student information, including assignments and grades, through the internet for school-related purposes. I give permission for my child to access the District’s technology resources, including District-approved online applications, and certify that the information contained on this form is correct. Parent’s or guardian’s name (print): Parent’s or guardian’s
Check one box. For which semester are you seeking financial aid? ❑ fall 2019 ❑ spring 2020 ❑ summer 2020
Check one box. If no box is checked, the Alternate Beneficiary is your Estate. Any balance in my Account not distributed to the above shall be distributed as follows: To my Children who survive me, in equal shares, as provided in No. 2 above To the following Alternate Beneficiary(ies) who survive me* in the indicated percentages: Name Social Security No. Percentage ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % ________________________________ ____________________ ____________ % Total __100__ % *If a beneficiary does not survive me, the amount which would have been distributed to that beneficiary shall be distributed to the other named beneficiary(ies) who survive me, in the proportion that the percentage indicated as passing to each such surviving beneficiary bears to the
Check one box. [ ] (a) The Holder represents that it is exercising the Warrants in an “offshore transaction” as defined in Regulation S under the United States Securities Act of 1933, as amended (the “1933 Act”) and is not a “U.S. Person” as defined in Regulation S (a “U.S. Person”) and is not exercising the Warrants on behalf of a U.S. Person.
