PARTICIPANT INFORMATION AND SIGNATURE PAGES Sample Clauses

PARTICIPANT INFORMATION AND SIGNATURE PAGES. Broker Name: Broker Phone: Fax: Primary Contact (If different than above): Primary Contact Phone: Fax: Broker/Authorized User License Number: Office Name: MLS Office ID: Vendor Information Vendor Name: Vendor Contact Person and Phone: Xxxxxx’s Authorized User’s Information Xxxxxx’s Authorized User’s Name and Phone: Data Information Request Broker requests providing the above-listed Vendor access to the following type of MichRIC® CIC Data for Broker or Broker’s Authorized User, as identified above: (Choose one from list below) Broker’s Office Listings Broker Reciprocity (IDX) Data Virtual Office Website (VOW) Data Other Data (Please be specific) [continued on next page] PARTICIPANT INFORMATION AND SIGNATURE PAGES (CONTINUED) Data Use (Authorized Purposes): The intended use of the MichRIC® CIC Data for Broker or Xxxxxx’s Authorized User Broker is as follows: (Choose one from list below) Broker’s Back Office Operation Broker Reciprocity (IDX) Website Virtual Office Website (VOW) Other (Please be specific) List all domain addresses including 2nd and 3rd levels where the MichRIC® CIC Data will be available for use: Xxxxxx and Xxxxxx’s Authorized User, if applicable, further agree and acknowledge they are bound by this Agreement and each of the undersigned represents and warrants that they have reviewed the Applicable Bylaws, Rules and Regulations, and/or Policies described in Paragraph 5 above and that they have consulted xxx.xxxxxxx.xxx to confirm that they have obtained the current versions of such requirements. Xxxxxx and Xxxxxx’s Authorized User, if included in this MichRIC® Data License Agreement, by signing below agree to the terms and conditions of this MichRIC® Data License Agreement. Xxxxxx agrees to notify MichRIC® within five (5) business days if Broker terminates its relationship with either Vendor or with Xxxxxx’s Authorized User. Broker Broker’s Authorized User Signature Signature Title Title Date Date Address for Notices: Address for Notices: Email Copy: Email Copy: VENDOR SIGNATURE PAGE Vendor agrees and acknowledges that it is bound by this Agreement and represents and warrants that it has reviewed the applicable Bylaws, Rules and Regulations and/or Policies relating to the MichRIC® CIC Data and that it has consulted xxx.xxxxxxx.xxx to confirm that it has obtained the current versions of such requirements. By signing below, Xxxxxx agrees to the terms and conditions of this MichRIC® Data License Agreement. Vendor Signature Print Name Date Vendor...
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Related to PARTICIPANT INFORMATION AND SIGNATURE PAGES

  • Participant Information My address is: My Social Security Number is:

  • Important Information The Employee agrees to indemnify and hold the Employer and National Benefit Services, LLC (NBS) harmless against any and all actions, claims, and demands that may arise from the purchase of annuities or custodial accounts in this 403(b)

  • Other Important Information Collection costs You agree to pay our reasonable costs for collecting amounts due, including reasonable attorneys’ fees and court costs incurred by us or another person or entity, to the extent not prohibited by applicable law and except as provided below.

  • Other Relevant Information This information shall always be in writing and shall address other relevant information as required by the contract or requested by the RFP. For example, in accordance with Section H, H106, Avoidance of Organizational Conflicts of Interest, identifying any situation in which the potential for a conflict of interest exists. If travel is specified in the TO PWS or statement of work, air fare and/or local mileage, per diem rates by total days, number of trips and number of contractor employees traveling shall be included in the cost proposal (see clause H047).

  • ADDITIONAL GRANT INFORMATION Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx SIGNATURE PAGE FOR SYSTEM AGENCY CONTRACT NO. HHS000663700012 HEALTH AND HUMAN SERVICES COMMISSION XXXX XXXX HOME, INC Xxxxx Ita Associate Commissioner Name: Title: Xxxxxx Xxxxx Chief Executive Officer Date of execution: _July 22, 2020 Date of execution: July 22, 2020 THE FOLLOWING ATTACHMENTS TO SYSTEM AGENCY CONTRACT NO. HHS000663700012 ARE HEREBY INCORPORATED BY REFERENCE: ATTACHMENT A STATEMENT OF WORK ATTACHMENT A-1 STATEMENT OF WORK SUPPLEMENTAL ATTACHMENT A-2 SUBSTANCE ABUSE PREVENTION AND TREATMENT (SAPT) BLOCK GRANT CONTRACT SUPPLEMENTAL ATTACHMENT B PROGRAM SERVICES & UNIT RATES ATTACHMENT C GENERAL AFFIRMATIONS ATTACHMENT D UNIFORM TERMS AND CONDITIONS-GRANTEE ATTACHMENT E SPECIAL CONDITIONS VERSION 1.2 ATTACHMENT F FEDERAL ASSURANCES AND CERTIFICATIONS ATTACHMENT G DATA USE AGREEMENT VERSION 8.5 ATTACHMENT H FISCAL FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA) FORM ATTACHMENT I SYSTEM AGENCY SOLICITATION NO. HHS0006637 INCLUDING ANY CLARIFICATIONS OR MODIFICATIONS MADE IN RESPONSE TO QUESTIONS SUBMITTED DURING POSTING AND ANY ADDENDUM ATTACHMENT X XXXXXXX’S PROPOSAL FOR SOLICITATION NO. HHS0006637 ATTACHMENTS FOLLOW ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR ADULTS SECTION I: PURPOSE Grantee shall provide substance use disorder treatment services to the target population at one or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning.

  • RESIDENT INFORMATION RESIDENT covenants that all application information is given voluntarily and knowingly by RESIDENT, and if such information proves to be false or misleading, MANAGEMENT may terminate this LEASE in accordance with applicable Virginia law; in which event, RESIDENT shall immediately vacate and surrender the PREMISES. RESIDENT shall notify MANAGEMENT of any changes to said application during the term of this lease or renewal thereof.

  • Student Information Those living in The Village hereby agree that the Owner shall receive all Student information provided in the Agreement and waives and releases Owner from any duty of confidentiality that may apply to such information.

  • Important Information About Procedures for Opening a New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial organizations to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, you are required to provide your name, residential address, date of birth, and identification number. We may require other information that will allow us to identify you.

  • Relevant Information The Issuer shall cause each Service Provider having Relevant Information in its possession to make such Relevant Information available to the Administrator and the Manager not later than 1:00 p.m., New York City time, at least five Business Days prior to each Payment Date.

  • Patient Information Each Party agrees to abide by all laws, rules, regulations, and orders of all applicable supranational, national, federal, state, provincial, and local governmental entities concerning the confidentiality or protection of patient identifiable information and/or patients’ protected health information, as defined by any other applicable legislation in the course of their performance under this Agreement.

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