MUST BE COMPLETED Sample Clauses

MUST BE COMPLETED. (for Tempus Unlimited, Inc. payroll processing: Client is authorized

MUST BE COMPLETED. Enter the mailing address if it is different from the legal address in line 8.

MUST BE COMPLETED. If my pet(s) identified on this record become ill, I request that the following veterinarian or veterinary practice, ! Countryside ! Other Clinic , provide all medical/surgical treatment it deems necessary, with fees not to exceed $ I acknowledge that in the event of my pet’s illness, the staff at the above named veterinary facility may not be able to contact me immediately. Nonetheless, they are authorized to initiate appropriate treatment until my agent or I can be reached. I agree to pay all related expenses associated with the treatment of my pet until I am available to discuss further care and related fees with the attending veterinarian.

MUST BE COMPLETED. I authorize NCUA to initiate electronic funds transfer payments to the credit union (and from the credit union if Xxx.Xxx option was elected). NAME OF AUTHORIZED REPRESENTATIVE TITLE SIGNED DATE 000-000-0000 xxxxxx@xxxx.xxx National Credit Union Administration Office of the Chief Financial Officer 0000 Xxxx Xxxxxx Alexandria, VA 22314-3428 OMB No. 3133-0135 PAPERWORK REDUCTION ACT STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time required to complete this collection of information is estimated to average 15 minutes per response. This includes time for reviewing the instructions, gathering needed information, and completing and reviewing the information. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send comments to xxxxxx@xxxx.xxx.

MUST BE COMPLETED. 0xx 0xx 0xx 0xx 0xx 0xx 1. Provider’s daily rate. $ $ 2. Meals: Enter daily cost (If cost of meal is included in the Provider’s Daily Rate on line 1, enter 0). $ $ 3. Transportation: Enter daily cost (If cost of transportation is included in the Provider’s Daily Rate on line 1, enter 0). $ $ 4. Add lines 1, 2, & 3, enter amount. TOTALS ARE THE PROVIDER’S PROJECTED DAILY CHILD CARE CHARGES. $ $ 5. Enter amount DES will subsidize the provider (See CC-214, Child Care Provider Rate Agreement). $ $ 6. Enter amount of Parent/Guardian’s daily DES Assigned Copaymant (See Certificate of Authorization). $ $ 7. Subtract line 6 from line 5 and enter amount. THIS IS THE DAILY RATE DES WILL REIMBURSE THE PROVIDER. $ $ 8. Subtract line 7 from line 4 and enter amount. THIS IS THE DAILY AMOUNT OF THE PROVIDER RATE NOT SUBSIDIZED BY DES, AND THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO REIMBURSE THE PROVIDER. $ $ DESCRIPTION FREQUENCY OF PAYMENT AMOUNT OF PAYMENT Registration Fees: $ Other (Specify): $ Other (Specify): $ 1st Child 3rd Child 2nd Child As the parent/guardian of the child(ren) in care, I agree to accept responsibility for the payment of the DES Assigned Full/Part Day Copayment on line 6, the Full/Part Day Charges listed on line 8 or any “Additional Fees.” PARENT/GUARDIAN’S SIGNATURE DATE As the provider, I understand that the DES will not monitor the parent/guardian’s payment for charges that exceed the Full/Part Day Charges on line 7, the Full/Part Day Charges listed on line 8 or any “Additional Fees.” CHILD CARE PROVIDER’S SIGNATURE DATE DISTRIBUTION: Original (white) - for provider; Copy (canary) – for parent/guardian CC-208 (5-11) – Page 47 Arizona Department of Economic Security Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (XXXX) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair...

MUST BE COMPLETED. Consumer / Non-Corporate Farm Credit Agreement And Statement of Disclosure

MUST BE COMPLETED. I authorize NCUA to initiate electronic funds transfer payments to the credit union (and from the credit union if Xxx.Xxx option was elected).

MUST BE COMPLETED. Please print

MUST BE COMPLETED. Configuring Devices The devices in an experimental set-up are defined as those components which require digital or serial control, (e.g. pumps, valves, auto sampler, etc.). Nine device definitions are supplied with the package. The first three are Cavaro devices which require serial control, the next six are digital devices which require TTL or switch control. The device definitions are given in Table II. An additional three user- specified device definitions may be added. These additional devices can be configured using the first option of the method menu. In preparation for the definition of a new device, the Device Description Data Sheet (Appendix 17.1) should be completed. A new definition at a specific definition number will overwrite the previous definition at that number. Table II : Default Device Definitions Name CP CS CV AP XX XX SV AS SW Action Pick Pick In Fwd Fwd Inj Adv Next True Disp Disp Out Rev Rev Load Home False Stop Stop Off Off Xxxxxx P P I F F I A N T D D O R R L H F T T O O Output 01 01 1 01 10 01 10 1 1 10 10 0 10 11 10 01 0 0 00 00 00 00 11 Pulse 0.0 0.0 0.0 0.0 0.0 0.0 0.3 5.0 0.0 To Configure a device, type: ο Config device. ο Enter the chosen device definition number. You can check the present status of the device definitions on the Notepad screen. User-specified device definitions are obtained by selecting Next page. ο Enter the device name. This is a two letter identification label (e.g. SV for selection valve) for the device. This label must be unique. ο Enter the number of actions the device must perform (e.g. 3 for forward, reverse, off). The maximum allowable number is three but fewer are permissible. If you require more than three actions, then you must split them over more than one device definition. ο Type in the action narration for action 1 (5 characters). Action 1 is the action to be depicted above the centre line in the Method time-line box. This narration will be used in the Time and Event box on the Method screen (see figure 4 section 2.3). ο Enter the digital output for action 1. Note - if the device is to be connected to more than one digital output point, for example points 5 and 6, and you want to set point 6 high then you must output a 2 (10 binary). To set point 5 high, output a 1 (01 binary). To set both high, output a 3 (11 binary). To set both points low, output a 0 (00 binary). ο Type in the hot key which will be used during method development to identify this action. This is usually the first letter of t...

MUST BE COMPLETED. If to the Contractor*: If to the Institution*: a t e w a y C o m m u n i t y C o l l e g e 2 h u r c h S t r e e t Xxx Xxxxx, XX 00000 t t n : D e a n M a r k Xxxxxxxx, PH.D New Haven Public Schools 00 Xxxxxx Xxxxxx Xxx Xxxxx, XX 00000 Attn: Xx. Xxxxx Xxxxxx