Emergency Contact Name. Phone No. Previous Address What type of pipe is on the property? PVC, Galvanized, Copper, Plex, or other. Please explain ***Any special circumstances for emergency care check if applies & initial Details required on a separate piece of paper. Residential Construction Only Multi units with count Consumer Signature: x Agent: x Commercial** (Please include: Sales Tax Certificate, W9 & Requesting Commercial Services Form) Commercial accounts only: DBA Business Type Commercial accounts Federal ID No. or Tax ID No. Consumers Signature: x Agent: x Xxxxxx County WC& ID No. 36 By: This document is Non-Transferable Date: 000 Xxxxxxxxx Xx., Xxxxxxx, XX 00000 * xxxxxxxxxxxxxxx@xxxxxx00.xxx *Phone 000-000-0000 * Fax 000-000-0000
Emergency Contact Name. Phone: ................................
Emergency Contact Name. Phone: ................................ Do you have any medical conditions relevant to your work? □ Yes □ No If yes please give details ..................................................................................................... Do you require a parking permit? □ Yes □ No Have you been issued with any keys to the ANBG or buildings? □ Yes □ No I have read and understood the Guidelines for Volunteers listed overleaf and agree to abide by those conditions.
Emergency Contact Name. Phone No. Previous Address ***Any special circumstances for emergency care check if applies & initial Details required on separate piece of paper. Residential Construction Only Multi units with count Consumers Signature: x Agent: x Commercial** (Please include: Sales Tax Certificate, W9 & Requesting Commercial Services Form) Commercial accounts only: DBA Business Type Commercial accounts Federal ID No. or Tax ID No. Consumers Signature: x Agent: x Xxxxxx County WC& ID No. 36 By: Date: This document is Non-Transferable 000 Xxxxxxxxx Xx., Xxxxxxx, XX 00000 * xxxxxxxxxxxxxxx@xxxxxx00.xxx *Phone 000-000-0000 * Fax 000-000-0000
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Emergency Contact Name. Home Phone: Cell: Other: Supervisors: Please keep a copy of this form for your records
Emergency Contact Name. Phone: Shore Manager for Commercial Operator Person we contact when we cannot reach you GUARANTOR Mandatory where the Customer is not a natural person. If applicable, see clause 23 of the Berth Rental Terms and Conditions. Full Name: AS SHOWN ON GOVERNMENT ISSUED IDENTIFICATION Address: Car Registration Vehicle 1: Direct Debit form submitted YES/NO Credit Card setup online YES/NO Vehicle 2: Note: A second parking permit is only eligible if a bank direct debit or credit card has been setup. VESSEL DETAILS Name: Vessel type: Yacht Launch Multi‐hull Commercial Vessel Model: Extreme Length: Beam: Draft: Weight: Is the Vessel equipped with holding tanks? YES/NO Colour Deck: Topside: Bottom: INSURANCE DETAILS The Customer acknowledges and agrees that it is a condition of the Agreement that the Customer holds protection and indemnity insurance cover of at least NZD$5,000,000 To cover any third party loss caused by the Customer or the Vessel) prior to its arrival at Westhaven Marina and maintains the same during the term of the Agreement. To this end, the Customer undertakes to provide the Manager with a copy of a ‘Certificate of Currency of Insurance’ for the Vessel prior to the arrival of the Vessel at Westhaven Marina and on renewal of such insurance. The Customer also acknowledges that the Manager recommends that the Customer effect and maintain marine hull insurance (to cover loss or damage to the Vessel). Initial In addition to the above, the Customer consents to the Manager directly making enquiries with the insurer of the Vessel on the Customer’s Behalf for updates as to the currency of the Customer’s insurance policy while the Vessel is berthed at the Marina. Insurance Company: Policy Holder Name: Policy Number: Expiry Date: POWER SUPPLY Do you wish to connect to shore power? Yes No My vessel does not have an EWOF, I will only plug temporarily in while I am on board EWOF Number: EWOF Expiry: COMMERCIAL OPERATOR Do you wish to undertake commercial activities from the berth? Yes No (Z Pier Charter Base) RENTAL DETAILS The Rental Fee shall be $ per day (including GST) plus utility charges as follows: Water: $4.50 per m3 (including GST) Power: $0.27 per kWh (including GST) (Note: Fees and utility charges are subject to change by the Manager from time to time) Please refer to the attached Berth Rental Terms and Conditions for conditions of payment. Berth(s)/Pile Mooring allocated: Westhaven Trust (for berths): Existing Marina Marina Extension EXECUTION I/we ac...
Emergency Contact Name. Relationship: Emergency Contact Phone (1) Phone (2) Photo/Image Release I grant permission for photos/images of the minor to be used by VUMC in any VUMC publication(s) and any other way VUMC deems necessary and appropriate to promote its activities and mission.
Emergency Contact Name. Phone# In consideration of Denver Zipline Tours, LLC services I, an adult visitor or parent of a minor visitor, acknowledge and agree as follows:
