Please check one Sample Clauses

Please check one. The employee will work at the alternate location days per week for a total of hours. His or her specific work schedule will be: . (This information is required for non-exempt USPS employees and is encouraged for all others.) The employee will work as needed when the following conditions exist: .

Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public Tax ID #: APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency ▇▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇ Zip Code 10041 Contact Person ▇▇▇▇▇▇ ▇▇▇▇▇▇ Title Director of M/WBE Program & Oversight Telephone # (▇▇▇) ▇▇▇-▇▇▇▇ Email ▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇.▇▇▇ Project Description (attach additional pages if necessary)

Please check one. Re-Enrollment New Registration How did you hear about our program? Alumni Family Friend/Family Website Facebook Other Last Name First Name Middle Name Name you would like your child to be called: Birth Date / / Sex Primary Home Language Parent/guardian primary home language Child’s Home address City State Zip List family members and pets your child lives with – include first names, relation and ages of siblings Are both parents at home? If no, which parent is present? General Comments: Home Address (include street, city, state, zip) Home Phone Number Cell Phone Number Employer Occupation Business Phone Number Email address (checked often) Best number to reach you at

Please check one. ☐ Yes ☐ No ☐ through an Individual Retirement Account (For U.S. domestic Subscribers only. Does not apply to foreign Subscribers.) ☐ through the Subscriber’s self-directed K▇▇▇▇ Plan Account. ☐ through another self-directed employee benefit plan as defined in Title I of ERISA.

Please check one. I did NOT subcontract out ANY portion of our work to another subcontractor. I DID subcontract out our work to:

Please check one. __________ a. The Plan requires the investment of each beneficiary or participant to be held in a segregated account and the Plan allows each beneficiary or participant to make his own investment decisions and, the decision to purchase the Shares has been made by the beneficiary or the participant and such beneficiary or participant is an Accredited Investor (Please have each such beneficiary or participant execute a separate Questionnaire). OR __________ b. The investment decisions made for the Plan are made by a plan fiduciary, whether a bank, an insurance company, or a registered investment advisor. OR __________ c. The Plan has total assets exceeding $5,000,000.

Please check one. All of the above dates and times are approved The above dates and times are approved EXCEPT: No Girl Scouts booths can be approved at this location. REASON: Set up booth (Outside): Grocery entrance Home living entrance Both Please specify where you would like troops to set up the Girl Scout cookie booth and any further instructions for them (i.e. will anything be provided, etc.)

Please check one. The Plan remains consistent with the educational needs of the school and/or district. ______ The Plan was reviewed and amended. __________________________ ________________________ __________________________ Supervisor’s Name (print) Title Signature The signature below indicates that this educator’s Individual Professional Development Plan was reviewed.

Please check one. Licensee provides purchase orders in the ordinary course of its business and a signed purchase order is attached to the executed copy of this Agreement. .