Daytime Telephone Number. Evening Telephone Number: Email address (E-mail address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim.): 1 The last four digits of the taxpayer identification number (TIN), consisting of a valid Social Security Number (SSN) for individuals or Employer Identification Number (EIN) for business entities, trusts, estates, etc., and the telephone number of the beneficial owner(s) may be used in verifying this claim.
Daytime Telephone Number. I hereby offer to pay a rent of £……….(in words)…………………………………… per calendar month for the above property, for a letting of ………years in accordance with the terms set out in the particulars. I hereby offer to pay £ for a yearly licence for the paddock land If offered the Tenancy, I would like to start the Agreement on 2022 PERSONAL DETAILS: Date of Birth of Tenderer and Wife/Partner: ............….............. /.............……….......... Family Details:...................................................................................................................
Daytime Telephone Number. Area Code ( ) --------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- Send premium and other notices regarding this policy to: D. ADDRESS: / / Insured's Address / /Applicant's Address OR STREET OR PO BOX: ---------------------------------------------------------------------------------------- CITY, STATE, ZIP (Country if other than U.S.A.): -----------------------------------------------------------------------
Daytime Telephone Number. Relationship to child The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to Queen Xxxx’s Grammar School staff to administer this medicine in accordance with the school’s Medical Needs Policy. I will inform the school immediately if there is any change in the details given above or if the medicine is stopped.
Daytime Telephone Number. The above information is, to the best of my knowledge, accurate at the time of writing and I give consent for the school to administer medicine in accordance with the school policy. I will inform the school immediately if there is any change in dosage or frequency to the medication or if the medicine is stopped.
Daytime Telephone Number. Employee’s E-Mail Address: Signature of Employee (Date) Signature of Authorized Benefits Representative (Date)
Daytime Telephone Number. II. GUARANTEE OF SIGNATURE(S) (See Instruction 1) Authorized Signature Name (Please Type or Print) Title Name of Firm Address Daytime Telephone Number Dated
Daytime Telephone Number. After Hours Telephone Number Mobile Telephone Number Email Address Bank Name Branch Name BSB Account Number Name on the Account In Case of Emergencies Next of Kin Name Relationship To You Next of Kin Daytime Telephone Number Next of Kin After Hours Telephone Number Next of Kin Mobile Telephone Number Next of Kin Email Address Details of EXISTING and PREVIOUS Scholarships, Cadetships or Bursaries Scholarship/Bursary Name Year Amount $ Length Have you been awarded any Allied Health Clinical Placement Scholarship(s) in the previous years for the same course of study? YES NO IF yes: provided details: Course Details Course Title Name of University Campus Student ID Number Course Coordinator Name Course Coordinator Telephone Number Course Coordinator Email University Clinical Placement Coordinator Name Clinical Placement Coordinator Telephone Number Clinical Placement Coordinator Email Address Start Date for Clinical Placement (dd/mm/yyyy) End Date for Clinical Placement (dd/mm/yyyy) Clinical Placement Facility Details Facility Name Street Address (NOT a PO BOX) Postal Address (if different from above) Telephone Number Fax Number Supervisor Name Supervisor Telephone Number Supervisor Email Address Accommodation Details (Provide Quote only)
Daytime Telephone Number. Relationship to child: ……………………………… Email Address: …………………………………………………………………… The above information is, to the best of my knowledge, accurate at the time of writing and I give consent for this medication to be administered to my child, in accordance with the above instructions and confirm that I have administered this medication in the past without adverse effect. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped. Signed: ……………………………………………………. Date: …………………………………. Please note that Parent/Carers are responsible for keeping medicines up-to-date, for notifying school of any changes and renewal of out-of-date medication and returning to dispensing pharmacy.
Daytime Telephone Number. Evening Telephone Number: Email Address (Email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim.): To view Garden City Group, LLC’s Privacy Notice, please visit xxxx://xxx.xxxxxxxxxxxxxxx.xxx/privacy 1The last four digits of the taxpayer identification number (TIN), consisting of a valid Social Security Number (SSN) for individuals or Employer Identification Number (EIN) for business entities, trusts, estates, etc., and the telephone number of the beneficial owner(s) may be used in verifying this claim.
