Please complete. Do you have an income tax reference number and if so, state it If you do not have an income tax reference number then disclose the amount of your income for the last 12 months R __ If you are a non-resident of South Africa then state your country of residence and your passport number Country Passport No. For what purpose do you intend to use the property [i.e. primary residence, rental, etc.] Are you a registered VAT vendor YES NO If you are a registered VAT vendor do you intend to claim any tax inputs arising from this transaction. If so what is your VAT registration number YES NO No. The Purchaser hereby acknowledges receipt of a copy of this agreement PURCHASER (1) PURCHASER (2) SCHEDULE ‘B1’ This must be a floor plan of the unit itself which must have dimensions recorded on the plan and a scale. SCHEDULE ‘B2’ This must be an elevation drawing of the building or the portion of the building in which the unit is situated with the unit marked with an “X” or a circle around the unit showing where in the building it is to be situated together with a ground layout showing where the exclusive use area/s marked with an “X” which the Purchaser is acquiring. List of specifications for construction and finishing. SCHEDULE ‘C’ SCHEDULE ‘D’
Please complete. It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to our staff in contacting you, processing your billing and notifying you in case of an office closing, etc. PATIENT INFORMATION SHEET Patient Name Maiden Name Marital Status: Date of Birth SS# Parent/Guardian Complete Address City State Zip Code Length of time there Home phone # Cell Phone# Employer Work Phone# Extension Closest Relative (Not Spouse) Relationship Telephone Name of Church/Affiliation Referral Source Spouse/Legal Guardian Name Address (if different from above) Date of Birth SS# Telephone Employer Job Title Work Telephone Extension Length of time there MEDICAL INFORMATION Primary Care Physician Name Physician’s Address Insurance Carrier ID# Group Policy Holder Name Policy Xxxxxx’s Date of Birth: Address (if different from above) *A 24-hour cancellation notification is required. There will be a late cancellation fee charged for appointments cancelled without at least a 24 business hour notice. This fee is NOT billable to any insurance carrier. **PLEASE NOTE: You will be held liable for any collection costs and/or attorney fees in the event those services are needed to collect this debt. ***By signing this form, you are indicating that you have read and understand the accompanying office policies. Signature Date Xxxxxxx Xxxxxxxxx, LCSW Western New York Psychotherapy Services 00 Xxxxxxx Xxx. 000 Xxxxxxx Xxxxx, Xxxxx 000 Orchard Park, New York 00000 Xxxxxxx, Xxx Xxxx 00000 Telephone: (000) 000-0000 Telephone: (000) 000-0000 Fax: (000) 000-0000 Fax: (716) 837 -6759
Please complete. 1. Please describe the person(s) or program(s) that have provided care for your child until now.
Please complete passed a Resolution in “RESOLVED that the Company enter into an Agreement of Lease substantially in the form of the lease to which this certificate is annexed, submitted to the Directors of the Company, and that PLEASE COMPLETE (name of Directory or authorised signatory) be authorised to execute the lease and any other documents that may be necessary to give effect thereto”.
Please complete. I would like to be kept informed of latest news and information from Catalina*. Yes No I confirm acceptance of my spa and have read and agree to the terms of the warranty. Yes No Customer………………………… Date………………… Dealer……………………………. Date…………………
Please complete. My name is My Class I understand and agree to abide by the Safe and Responsible Behaviour Expectations.
Please complete. Federal Tax ID No.: ----------------------------------------- ----------------- (Agency Name) By: Date: ------------------------------------- ------------------------------- Title: ------------------------------------------ INSTRUCTIONS: This form should be sent to Donegal Group Inc., 1195 River Road, Marietta, Pennsylvaxxx 00000, Xxxxxxxxx: Xxxxx X. Xxxxxxx, Xxxxxr Vice Presidxxx, Xxxxx Xxxxxcial Officer and Secretary, along with a Subscription Agreement if not previously submitted for the Subscription Period and your check and be received prior to September 30 or March 31 of the respective Subscription Period or, in the case of the first Subscription Period, by October 31, 2001. The dollar amount set forth above must be at least $1,000 and may not exceed, when added to the amounts paid under the direct bill commission payment method and/ox xxe contingent commission payment method for the current Subscription Period, an aggregate of $12,000. September , 2001 ------ RE: IMPORTANT CHANGES TO THE DONEGAL AGENCY STOCK PURCHASE PLAN Dear Agent: Enclosed is a brochure highlighting the new Donegal Agency Stock Purchase Plan (the Plan), a Plan prospectus, latest Donegal Group Inc. Annual Report and Form 10-Q, and a Subscription Agreement form. Due to the recent recapitalization of Donegal Group Inc. that created two separate classes of common stock, the Company was required to adopt a new Agency Stock Purchase Plan. AS A RESULT, ALL PARTICIPANTS IN THE PREVIOUS PLAN MUST RE-ENROLL IN THE NEW PLAN IN ORDER TO CONTINUE TO PARTICIPATE IN A COMMISSION WITHHOLDING METHOD. Any funds remaining in your current account after the purchase of stock on September 30, 2001, will be returned to you. The first subscription period of the new Plan will commence on October 1, 2001 and end on March 31, 2002. If you elect to participate in this subscription period, please complete the enclosed Subscription Agreement form indicating your preference of payment method. If you select the lump sum payment method, the Subscription Agreement and payment may be submitted at any time prior to the end of the subscription period. If you select the direct bill or contingent commission method, xxe Subscription Agreement must be submitted to our office prior to November 1, 2001, in order for your agency to be enrolled in the first subscription period. Should any questions arise, please feel free to contact Dan Wagner or Jeff Miller at 1-888-800-0000. Sincerely, Ralph G. Spontak Senior Vice Preside...
Please complete. In the case of a work-related injury, the employee agrees to report the injury immediately to the UF Workers’ Compensation Office, (000) 000-0000, to get instructions for obtaining medical treatment and complete the required documentation. When the remote location is in the home, workers’ compensation does not cover injuries that are not job related. Employees who work out of state or out of the country in one location for more than 30 days need workers’ compensation coverage specific to that location. Specific Work Schedule: Days per week for total number of hours (If necessary, report to primary UF work location within reasonable time frame) M T W R F S U Total hours per week: Work Plan Description (include position description): Specific description of dedicated workspace: Time Period (start and end dates): Annual renewal, OPS agreements must be renewed every 6 months Start Date: End Date: List equipment to be furnished by the university for use in the remote work location (include property decals where appropriate): List all additional equipment, supplies, and services that will be furnished by the employee: List the arrangement agreed upon for handling telephone calls made by the employee working at the alternate location: List the arrangement agreed upon for providing Internet access by the employee working at the remote location: List the arrangement agreed upon for providing personal care for a child or dependent adult during scheduled work hours: The employee agrees to obtain their messages from the department at least how many times a day: Additional conditions agreed upon by the employee and supervisor are as follows (when coworkers may have access to the employee, when telephone calls may be expected, etc.): Working fewer hours than FTE, remaining hours will be covered by: Leave, Leave without Pay, Work at the official university work location, or Not applicable (Appropriate supervisor must approve any changes to schedule in advance) The information I have provided in this agreement is accurate and true to the best of my knowledge and will be followed under the direction of my supervisor. I understand that if any information changes, it is my continuing duty to inform my supervisor and initiate the completion of an updated agreement. I agree that, among other things, I am responsible for establishing specific work hours during which I may be reached directly; furnishing and maintaining my remote work location in a safe manner; receiving permiss...
Please complete. Undersigned’s Term Loan hold amount immediately prior to the Restatement Effective Date: $ __________ Very truly yours, _______________________________________, By: Name: Title:: By: * Name: Title:: * If a second signature is needed. [Participation Notice - Signature Page] Schedule I Additional Term Loans: Lender Amount Barclays Bank PLC $ 356,079,554.57 Rollover Term Loans: Each Converting Lender (including the Fronting Banks with respect to Reallocated Term Loans, if any), shall be deemed to have a Restatement Effective Date Term Commitment in an aggregate principal amount equal to the outstanding principal amount of Existing Term Loans or Reallocated Term Loans of such Converting Lender that are exchanged for Restatement Effective Date Term Loans in accordance with this Agreement. Restatement Effective Date Revolving Commitments: Lender Amount Barclays Bank PLC $30,000,000 Healthcare Financial Solutions, LLC $27,500,000 SunTrust Bank $30,000,000 Credit Suisse AG $15,000,000 Royal Bank of Canada $15,000,000 EXHIBIT B Pledge and Security Agreement Schedules* [Attached] * Confidential treatment has been requested with respect to all the redacted portions of the document, which has been filed separately with the Securities and Exchange Commission. ANNEX I [See attached]
Please complete. Do you have an income tax reference number and if so, state it If you do not have an income tax reference number then disclose the amount of your income for the last 12 months R If you are a non-resident of South Africa then state your country of residence and your passport number Country Passport No. For what purpose do you intend to use the property [i.e. primary residence, rental, etc.] Are you a registered VAT vendor YES NO If you are a registered VAT vendor do you intend to claim any tax inputs arising from this transaction. If so what is your VAT registration number YES NO No. The Purchaser hereby acknowledges receipt of a copy of this agreement PURCHASER (1) PURCHASER (2) Schedule “A1” AMOUNT OF BOND TO BE REGISTERED ESTIMATED ATTORNEY’S BOND FEES & DISBURSEMENTS [INCL VAT] [**excluding bank fees – see below] R500,000.00 – R600,000.00 R16,973.50 R600,000.00 – R700,000.00 R18,744.50 R700,000.00 – R800,000.00 R20,772.50 R800,000.00 – R900,000.00 R22,543.50 R900,000.00 – R1,000,000.00 R24,445.50 R1,000,000.00 – R1,100,000.00 R26,216.50 R1,100,000.00 – R1,200,000.00 R28,113.50 R1,200,000.00 – R1,300,000.00 R28,113.50 R1,300,000.00 – R1,400,000.00 R29,884.50 R1,400,000.00 – R1,500,000.00 R29,884.50 R1,500,000.00 – R1,600,000.00 R31,655.50 R1,600,000.00 – R1,700,000.00 R31,655.50
