Client Contact Information. Please provide the Contact Information for those involved in the administration of your plan. NOTE: Only one person may be the Primary contact for each section. Contact #1: Name: Title: Phone: Fax: Email: Primary Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Additional Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding (continued) Contact #2: Name: Title: Phone: Fax: Email: Primary Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Additional Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Contact #3: Name: Title: Phone: Fax: Email: Primary Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Additional Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding
Client Contact Information. The contact information of Client(s) is set forth below: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client agrees to immediately update Broker of any changes to the above referenced information. SPECIAL STIPULATIONS: The following Special Stipulations, if conflicting with any exhibit, addendum, or preceding paragraph, shall control: Additional Special Stipulations are □ or are not □ attached. BY SIGNING THIS AGREEMENT, BUYER ACKNOWLEDGES THAT: (1) BUYER HAS READ ALL PROVISIONS AND DISCLOSURES MADE HEREIN; (2) BUYER UNDERSTANDS ALL SUCH PROVISIONS AND DISCLOSURES AND HAS ENTERED INTO THIS AGREEMENT VOLUNTARILY; AND (3) BUYER IS NOT SUBJECT TO A CURRENT BUYER BROKERAGE AGREEMENT WITH ANY OTHER BROKER. RECEIPT OF A COPY OF THIS AGREEMENT IS HEREBY ACKNOWLEDGED BY BUYER. The above Agreement is hereby accepted, o’clock .m., on the date of . Broker Buyer’s Signature Address: Print or Type Name Buyer’s Signature MLS Office Code Brokerage Firm License Number Print or Type Name Broker’s Phone# & FAX# By: Broker or Broker’s Affiliated Licensee Print or Type Name Agent’s Georgia Real Estate License Number Email Address:
Client Contact Information. The Contact Person is the person within the Client organization who is selected by the Client to authorize user access to Employer Online Services. Contact Person: Contact Telephone Number: Contact E-mail Address:
Client Contact Information. The contact information of Client(s) is set forth below: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client agrees to immediately update Broker of any changes to the above referenced information.
Client Contact Information. The contact information of Client(s) is set forth below: _Buyer's Name Here Client Name _Buyer's Mailing Address Address for Receiving Notice Business Telephone: Buyer's Work Number Home Telephone: Xxxxx's Home Number Cell Phone: Buyer's Cell Number Facsimile Number: Buyer's Fax Number E-mail Address: Buyer's E-mail Address _Spouse or Partner's Information Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client agrees to immediately update Broker of any changes to the above referenced information. SPECIAL STIPULATIONS: The following Special Stipulations, if conflicting with any exhibit, addendum, or preceding paragraph, shall control: This Buyer Brokerage Agreement is filled out only as an example. This document will be properly filled out and signed by all parties involved. Please let us know if you have any questions or concerns regarding this document. BY SIGNING THIS AGREEMENT, BUYER ACKNOWLEDGES THAT: (1) BUYER HAS READ ALL PROVISIONS AND DISCLOSURES MADE HEREIN; (2) BUYER UNDERSTANDS ALL SUCH PROVISIONS AND DISCLOSURES AND HAS ENTERED INTO THIS AGREEMENT VOLUNTARILY; AND (3) BUYER IS NOT SUBJECT TO A CURRENT BUYER BROKERAGE AGREEMENT WITH ANY OTHER BROKER. RECEIPT OF A COPY OF THIS AGREEMENT IS HEREBY ACKNOWLEDGED BY BUYER. The above Agreement is hereby accepted, o’clock .m., on the date of . _Keller Xxxxxxxx Realty-Peachtree Battle Broker Buyer’s Signature Address: 0000 Xxxxxxxxx Xx. Xxxxx X Buyer's Name Here Print or Type Name Xxxxxxx, XX 00000 Buyer’s Signature KWPB01 H-54627 Spouse or Partner Name Here MLS Office Code Brokerage Firm License Number Print or Type Name Broker’s Phone#_000-000-0000 & FAX#_000-000-0000 By: Broker or Broker’s Affiliated Licensee The Xxxxxxxxxxx Team Print or Type Name Agent's License Number Agent’s Georgia Real Estate License Number
Client Contact Information. Please fill out the following information, which will be used by our deployment & accounting teams. Billing Contact Xxxxx Xxxxxxxx Title Accounts Payable Address 000 X Xxxxxx Xxx City, State Zip Post Falls, ID 83854 Phone 000-000-0000 Email xxxxxxxxx@xx000.xxx Project Contact Xxxx Xxxxxxxxx Title Technology Director Phone 000-000-0000 Email xxxxxxxxxx@xx000.xxx *Executive Sponsor (Head of School, Business Manager/CFO, etc.) Xxxxx Xxx Title Business Manager/CFO Email xxxx@xx000.xxx
Client Contact Information. Address: Telephone: Email: Date of Event: Time of Event: Event Location: The following outlines the food that will be provided to the client on the date of the event: • 1 • 2 • 3 • 4 • 5
Client Contact Information. Owner: Telephone: Co-Owner:
Client Contact Information. CLIENT shall provide a valid, confidential FAX number on the standard PATHGROUP Provider Fax Verification Form.
Client Contact Information. (Please provide to Custodian written notice of any changes. Changes will be effective when received by Custodian.) 0 X. Xxxxx Street Street Address (required) Post Office Box Number Cartersville GA 30120 City State Zip Code Email Address 000-000-0000 000-000-0000 Phone Fax THIS AGREEMENT is made by and between the undersigned Account owner, as Client, and Salem Trust Company, as Custodian. It is understood and agreed that Client is the owner of all the Assets and that Custodian is acting as the agent of Client designated to administer the Assets pursuant to powers set forth in this Agreement. For valuable consideration, Client and Custodian agree that all Assets deposited in this Account will be managed and administered according to the following provisions of this Agreement:
