Exclusion Form Sample Clauses

Exclusion Form. The Election Not to Participate In (“Opt Out” From) Class Action Settlement, substantially like the form attached hereto as Exhibit B, subject to Court approval.

Exclusion Form. “Exclusion Form” means the document, attached hereto as Exhibit 4, and used by Class Members to request exclusion (i.e. opt-out) of the proposed Settlement Agreement.

Exclusion Form. A valid and timely opt-out statement by a Class Member submitted to the Settlement Administrator asking to be excluded from the Settlement, as described further in Section III.9(d).

Exclusion Form. In the Matter of Xxxxxxx x. Xxxxxx’x, Inc. et al., U.S. District Court, Northern District of California Case No. 3:15-CV-00815-WHA IF YOU WANT TO EXCLUDE YOURSELF FROM THE CLASS SETTLEMENT IN THIS ACTION, YOU MUST COMPLETE, SIGN, AND MAIL THIS EXCLUSION FORM IN THE ENCLOSED PRE-PAID ENVELOPE, ON OR BEFORE [45 DAYS FROM MAILED NOTICE]. I wish to opt-out (exclude) myself from the Class Settlement. Print Name: Address: Signature: Mail Completed Exclusion Form by [45 DAYS FROM MAILED NOTICE] to: Simpluris, Inc. [ADDRESS] EXHIBIT 3 (Claim Form) CLAIM FORM – REST PERIODS In the Matter of Xxxxxxx x. Xxxxxx’x, Inc. et al.,

Exclusion Form. Election Not to Participate or Opt-out statement by a Class Member, as described further in Section III.9.d.

Exclusion Form. If you wish to be excluded from the Class, you must mail the request for exclusion to the Class Administrator, Simpluris, Inc., using the Exclusion Form below, so that it is postmarked no later than <DATE>: R EQUEST TO BE EXCLUDED FROM CLASS ACTION SETTLEMENT Xxxx X. Xxxxx, et xx x. Temecula Motorsports, Inc., et al. Riverside County Superior Court, case number MCC1500556 To be excluded from the class action settlement, you must complete and mail this form to the class administrator at the address below, postmarked on or before < DATE>: Name: Address: Telephone: IF YOU SEND IN THIS FORM, YOU WILL NOT RECEIVE A SETTLEMENT PAYMENT. RATHER, IF YOU USE THIS FORM, YOU WILL BE EXCLUDED FROM THE SETTLEMENT, AND WILL NOT BE BOUND BY ITS TERMS AND CONDITIONS. I received notice of a settlement and I request to be excluded from the class action settlement in the above-entitled case. Dated: (sign here) Mail this Form to: EXHIBIT C OBJECTION FORM If you wish to object to the Settlement, you must submit the objection to the Class Administrator, Simpluris, Inc., using the Objection Form below, so that it is postmarked no later than <DATE>: OBJECTION TO CLASS ACTION SETTLEMENT Xxxx X. Xxxxx, et al v. Temecula Motorsports, Inc., et al. Riverside County Superior Court, case number MCC1500556 NOTE: DO NOT FILL OUT OR SEND IN THIS FORM UNLESS YOU OBJECT TO THE TERMS AND/OR CONDITIONS OF THE PROPOSED SETTLEMENT. To object to the class action settlement, you must complete and mail this form to the class administrator at the address below, postmarked on or before <DATE>. Name: Address: Telephone: I received notice of a settlement and I object to the class action settlement in the above-entitled case. The reasons for my objection are as follows (attach additional sheet if more space is required) Dated: (sign here) Mail this Form to: EXHIBIT D EXHIBIT E Transportation License & Documentation EXHIBIT F 3/16/2018 New 2017 Yamaha YZF-R6 Motorcycles in Murrieta, CA | Stock Number: Y000710 xxxxxxxxxxxxxxxxxxx.xxx FOLLOW US | (000) 000-0000 2017 Yamaha YZF-R6 Supersport • New ON SALE $8,999 SALE PRICE MSRP: $12,574 Factory Rebate $500.00 TMS Discount $3,075.00   3/16/2018 New 2017 Yamaha YZF-R6 Motorcycles in Murrieta, CA | Stock Number: Y000710 SUBMIT First Name Last Name Zip Code Phone Number Email Address  Request More Information I'm not a robot reCAPTCHA Privacy - Terms  APPLY FOR FINANCING   2017 Yamaha YZF-R6 • $8,999 Condition New Stock Number Y000710 Model Type Supersport...

Exclusion Form. There may be clients that are not appropriate for cognitive behavioral group/individual therapy. Client excluded from this Clinical Pathway, must have an alternative approved clinical path. Please complete the following for approval if you feel your client should be excluded. Date: Client Name: Client Number: Rational for Exclusion: • Homicidal Client • Suicidal Client • Psychotic Client • Alzheimer’s With Agitation • Autism With Aggression • Catatonia • Moderate To Severe Intellectual Disability With Anxiety • other: (please describe) Physician Extender Date Supervisor ’s Signature Date Name: _ Medical Record #