Name Telephone Number. FOR THE BUYER: Ian X.X. Xxxxxx (000) 000-0000
Name Telephone Number. My signature indicates that I have read and agree to be bound by the conditions noted on the following six pages of this application/agreement. Signature of Resident Date Signature of Parent/Guardian Date (If applicant is younger than 18 years of age) OFFICE USE ONLY: PLEASE DO NOT WRITE BELOW THIS LINE ID Number Room Assignment 1 Room Assignment 2 Date Received Date Date RESIDENCE LIFE AGREEMENT
Name Telephone Number. Xxxxxx Xxxxxxxx (000) 000-0000 Xxxxx XxXxxxxxxx (000) 000-0000
Name Telephone Number. GENERAL INFORMATION Brand name of panel most commonly used by your company: Type of receiver format you prefer: Please indicate the best method for contacting you after business hours. Service Pager Home Mobile Number Leave Message? Yes No Company Name to Use When Dispatching: Phone number to give to your customers: Phone number to transfer your customers to: CONTACT INFORMATION Billing Contact Name: Phone: Email: Data Entry Name: Phone: Email: Activity Reports Name: Phone: Email: Runaway Accounts: Name: Phone: Email: Name: Phone: Email: Name: REPRESENTATIVES Phone: Email: List all owners, officers and employees who will be in contact with the Central Station for any reason pertaining to your company’s accounts. Each representative should have a unique PIN that is 5 numbers in length. Email Addresses are required for NetConnect access. User names will be first initial and last name with the first two letters capitalized. NetConnect login is case sensitive.
Name Telephone Number. NOTE TO INTERESTED VENDORS* – Due to security concerns, all offerors must contact the above U.S. Government representative and email the names and company name of all individuals who will represent the company at the pre-proposal conference to xxxxxx-xxx-xxxxxxxxx@xxxxx.xxx . On the date of the pre-proposal conference, company representatives must present matching photo identification in order to be allowed access. Anyone attempting to attend the pre-proposal conference without prior notification will be denied entry.
Name Telephone Number. [ ] [ ] Telephone call-backs shall be made to the Underwriters and the Company if joint instructions are required pursuant to this Escrow Agreement. EXHIBIT D [Form of Subscription Termination Notice] ________, 2015 [American Stock Transfer & Trust Company, LLC 6000 00xx Xxxxxx Xxxxxxxx, Xxx Xxxx 00000 Attention: Corporate Actions] Dear : Pursuant to the Escrow Agreement dated as of [ ], 2015 (the “Escrow Agreement”) by and among Sxxxxx & Company, Inc. (the “Company”), WX Xxxxxxxxx + Co., LLC, as representative of the several underwriters party to that certain Underwriting Agreement, dated [ ], 2015, and [American Stock Transfer & Trust Company, LLC], the Company hereby notifies you that the following subscription(s) have been rejected: Name of Subscriber Amount of Subscribed Shares [Units] Rejected Dollar Amount of Rejected Subscription SXXXXX & COMPANY, INC. By: Name: Title:
Name Telephone Number. 1. Xxxxx Xxxxxxx (000) 000-0000 Office (000) 000-0000 Cell Phone
Name Telephone Number. I consent for my therapist and office manager to communicate with me by mail and phone at the following location, & number, and I will provide timely notification of any changes.
Name Telephone Number. 1. [Contact] [Phone Number] If to the Stockholder Representative: Name Telephone Number
Name Telephone Number. 2. Telephone call backs shall be made to each party if joint instructions are required pursuant to the agreement. All funds transfer instructions must include the signature of the person(s) authorizing said funds transfer and must not be the same person confirming said transfer. EXHIBIT B SCHEDULE OF ESCROW AGENT FEES Escrow Agent Services New Account Acceptance Fee $ 0 Payable upon Account Opening Minimum Administrative Fee $ 3,000 Payable Upon Account Opening and in Advance each year in which we act as Escrow Agent A New Account Acceptance Fee will be charged for the Bank’s review of the Escrow Agreement along with any related account documentation. The account will be invoiced in the month in which the account is opened and annually thereafter and fees will not be pro-rated. Payment of the invoice is due 30 days following receipt. The Administrative Fee will cover a maximum of ten (10) annual administrative hours for the Bank’s standard Escrow services including account setup, safekeeping of assets, investment of funds, collection of income and other receipts, preparation of statements comprising account activity and asset listing, and distribution of assets in accordance with the specific terms of the Escrow Agreement. These fees cover a full year, or any part thereof, and thus are not prorated in the year of termination.
