Participant’s Signature. Date: Administrative Use Only Internal Log # _ Date Received by Staff: Staff Name and Position: Grievance Type: ☐ Grievance ☐ Appeal #:4256 Attachment 3 County of Orange Health Care Agency, Office of Care Coordination Shelter Grievance Process The Shelter Grievance Process document is intended to provide Shelter Participants information on their grievance rights and an overview of the process. The County of Orange (County) appreciates feedback and takes grievances seriously. The County will work to resolve Participant grievances in a transparent and efficient manner. If you as a Shelter Participant are unsure of how to access the shelter grievance process within the shelter you are staying, you can reference the information provided during the intake process, ask a shelter staff member, or review grievance information posted in the common areas of the shelter. If at any time during the process you experience difficulty with the shelter grievance process, please reference the Contact Information in Step 3 (below) to contact the County directly via telephone, email and/or mail.
Participant’s Signature. If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Oconee Federal Financial Corp. (the “Company”) or its affiliate on , of stock certificates for shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Oconee Federal Financial Corp. 2012 Equity Incentive Plan, as applicable, which shares were transferred to me on the Company’s stock record books on . Date: Participant’s signature
Participant’s Signature. Date: Administrative Use Only Internal Log # _ Date Received by Staff: Staff Name and Position: Grievance Type: ☐ Grievance ☐ Appeal DocuSign Envelope ID: 34D2C0D8-17A6-4D6E-922C-77E8D580EEC8 #:4256 Attachment 3 County of Orange Health Care Agency, Office of Care Coordination Shelter Grievance Process The Shelter Grievance Process document is intended to provide Shelter Participants information on their grievance rights and an overview of the process. The County of Orange (County) appreciates feedback and takes grievances seriously. The County will work to resolve Participant grievances in a transparent and efficient manner. If you as a Shelter Participant are unsure of how to access the shelter grievance process within the shelter you are staying, you can reference the information provided during the intake process, ask a shelter staff member, or review grievance information posted in the common areas of the shelter. If at any time during the process you experience difficulty with the shelter grievance process, please reference the Contact Information in Step 3 (below) to contact the County directly via telephone, email and/or mail.
Participant’s Signature. DATE: / / The Information Practices Act of 1977 (Civil Code §1798.17) and the Federal Privacy Act of 1974 (Title 5, United States Code §552a(e)(3), §7 Note) require that this notice be provided when collecting personal information and Social Security numbers from individuals. Information requested on this form is used by CalSTRS, Active Financial Choices for the purposes of identification. Legal references authorizing solicitation and maintenance of this personal information include Education Code Sections 24950 and 24975, Government Code Sections 1151 and 1153, and Title 26, United States Code (Internal Revenue Code) Sections 6011 and 6051. It is mandatory to furnish all information requested on this form. Failure to provide the mandatory information may result in the enrollment action If you have any questions, please contact a Customer Service Associate at (000) 000-0000 or go online at Xxxxxxx0.xxx. Customer Service Associates are available Monday through Friday, 8:00 A.M. to 5:00 P.M. Pacific Time (excluding stock market holidays).
Participant’s Signature. I have received, read, and agree to be bound by the terms of the prospectus for each fund in which I am investing. If I am purchasing shares after reviewing a fund profile, I understand that I will receive the prospectus after I purchase shares in the fund. I have the authority and legal capacity to purchase mutual fund shares, am of legal age in my state, and believe each investment is suitable for me. I authorize the X. Xxxx Price Funds (Funds) and their agents to act on any instructions believed to be genuine for any service authorized on this form, including telephone/computer services. The Funds use reasonable procedures to verify the identity of the shareholder and the person(s) granted trading privileges, if applicable, when servicing an account by telephone. I understand that it is X. Xxxx Price’s policy to accept transaction instructions from and provide account information to the registered account owner(s) only, unless the account owner(s) has pro- vided written authorization to X. Xxxx Price to grant trading privileges to another person. I further understand that it is my responsibility to monitor the activity in my account and not to provide account information, includ- ing my online user name and password, to anyone. The Funds and their agents are not liable for any losses that may occur from acting on unauthorized instructions. All services are subject to conditions set forth in each fund’s prospectus. Opening a new account: I have read and agree to the terms and conditions set forth in the X. Xxxx Price 403(b)
Participant’s Signature. Date: *Must be at least eighteen 18 years old of age Parent's signature: Date: (if student is under 18 years of age): CONSENT TO RELEASE INFORMATION ABOUT TRAVELER Student or Participant’s Full Name _ _ • I authorize employees, agents, and representatives of the University of the Incarnate Word (UIW) and the host institution abroad to release to the United States Government and to the host institution abroad, and their employees, agents, and representatives, information in the possession of UIW regarding my location, status, welfare, intentions, or problems. • I further authorize UIW to release to those persons named below, information in the possession of UIW regarding my location, status, welfare, intentions, or problems. • I grant permission to the officials of the University of the Incarnate Word to provide copies of written records, permit inspection and review of the contents of my education records, and/or to discuss my academic performance in connection with my student organization international activity, program and/or excursion with the following person(s) as authorized by the Federal Educational Rights and Privacy Act.
Participant’s Signature. By its signature below, Participant acknowledges that it has read and understands this Participation Agreement and agrees to comply with all of the terms and conditions set forth herein. If Participant is the Qualifying System Owner, Participant gives permission for Distributor and TVA to review the interconnection of the Qualifying System at the Address. Participant understands that the Qualifying System is not entitled to generate power and Participant is not entitled to Generation Credits or rebates unless and until Distributor and TVA execute this Participation Agreement and the System Acceptance Form. Participant hereby warrants and certifies that all information submitted in this Participation Agreement is accurate and the Participant has the authority to enter into this Participation Agreement. In making this warranty and certification, Participant acknowledges that Participant is aware that Section 21 of the Tennessee Valley Authority Act of 1933, as amended, (16 U.S.C. § 831t) provides criminal sanctions including fines and imprisonment for any person who is convicted of, among other things, defrauding TVA. Specifically, Participant understands that Participant is bound by the then-current Guidelines in effect at the time TVA executes this Participation Agreement, and the Guidelines in effect at the time TVA executes this Participation Agreement can be different than what the Participant has reviewed. Participant is responsible for reading, understanding, and adhering to the then-current Guidelines in effect at the time TVA executes this Participation Agreement. Participant accepted and agreed to the foregoing this day of , 20 . Participant Name Participant’s Authorized Officer Name & Title (please complete only if Participant is a commercial or industrial customer) Participant or Participant’s Authorized Representative Signature
Participant’s Signature. Home Address City, State, Zip Code Home Telephone Number Staff Initials Business Telephone Number PARENT’S / GUARDIAN’S: CONSENT, LICENSE & LIABILITY RELEASE AGREEMENT (TO USE MY CHILD’S IMAGE, VOICE, NAME, AND/OR LIKENESS) The City of Glendale (“City”) and/or the Glendale Parks & Open Space Foundation (“GPOSF”) would like to use my child’s image, voice, name, and/or likeness to share my story or experience as it relates to my child’s participation in the activities of the 2020 Trails & Open Space Program. I, , the parent/guardian of , understand that City and/or GPOSF may take photographs, videotape, other images, and/or voice recordings of my child and/or my child’s likeness while my child participates in the activities of the 2020 Trails & Open Space Program and I hereby consent to City’s and/or GPOSF’s doing so. I hereby grant
Participant’s Signature. Home Address City, State, Zip Code Home Telephone Number Staff Initials PARENT’S / GUARDIAN’S: RELEASE OF LIABILITY & INDEMNITY AGREEMENT I, , the parent/guardian of , acknowledge that my child has voluntarily applied to participate in volunteer maintenance and clean-up activities sponsored by the City of Glendale’s Community Services & Parks Department (“the City”) and the Glendale Parks & Open Space Foundation (“the Foundation”) on one or more days during this year at the Glendale Narrows Riverwalk Park. Activities include, but are not limited to: weeding, sweeping the paved trail, removing graffiti, spreading or leveling mulch, cleaning signs, picking up litter, and raking leaves or plant debris. I understand and agree that my child’s clean-up activities take place outdoors during daytime hours in the Glendale Narrows Riverwalk Park, on walking or bicycle paths that may be unpaved, or in planter areas, all of which have uneven surfaces. Working in those areas has risks, including (but not limited to) the risk of: falling, heat exhaustion, insect or animal bites, poisonous plants, cuts and scrapes, and cold or hot weather conditions. I also understand and agree that while my child participates in the maintenance and clean-up activities, an activity leader designated by the City of Glendale Community Services & Parks Department will guide my child. I represent that my child is: (1) in good physical condition and emotional health, (2) not suffering from any condition, disease, or disability that can hinder or endanger my child’s participation in the maintenance and clean-up activities, and (3) qualified to participate in the maintenance and clean-up activities. PLEASE INITIAL: . I UNDERSTAND THAT SERIOUS ACCIDENTS OCCASIONALLY OCCUR DURING MY CHILD’S PARTICIPATION IN MAINTENANCE AND CLEAN-UP ACTIVITIES AND THAT THE ACTIVITIES HAVE A RISK OF INJURY OR DEATH. I AM FULLY AWARE THAT MY CHILD IS VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH MY KNOWLEDGE OF THE INHERENT RISKS AND HAZARDS INVOLVED. I HEREBY AGREE TO ACCEPT ON MY CHILD’S BEHALF ANY AND ALL RISKS OF INJURY, DEATH, OR PROPERTY DAMAGE. PLEASE INITIAL: . AS LAWFUL CONSIDERATION for the City’s permitting my child to participate in the maintenance and clean-up activities, I HEREBY AGREE that I, my child, our heirs, distributees, guardians, legal representatives, and assigns WILL NOT MAKE A CLAIM AGAINST, XXX, OR PROSECUTE the City, or the Foundation, or both, their officers, agents, or employees fo...
Participant’s Signature s/ Kennxxx X. Xxxxxxx -------------------------------------------- Print Name: Kennxxx X. Xxxxxxx -------------------------------------------- Date: 12/31/98 -------------------------------------------- Approved: NEW JERSEY STATE MEDICAL UNDERWRITERS, INC. -------------------------------------------- By: /s/ Danixx Xxxxxxxx -------------------------------------------- Print Name: Danixx Xxxxxxxx -------------------------------------------- Date: 12/31/98 --------------------------------------------
