PLEASE PRINT Sample Clauses

PLEASE PRINT. (* An asterisk indicates that the information is required for processing.) E-mail Address: (Enter an active e-mail address for electronic communication purposes.) Spouse/Partner Name: *Billing Address: _ *City: *State: _ *Zip: _ *Primary Contact Phone: ( _) - Cell Phone: ( _) - Fax Number: ( _) _- *Emergency Contact Name: *Address: *City: _ *State: *Zip: *Emergency Phone Number: ( ) - Employer Name: Work Phone: ( ) - MDU Account Holder Name Signature Name that will appear on the xxxx-financially responsible person or entity Date: _ FOR OFFICE USE ONLY CSA ID# Processed by: Date: Continuous Service Agreement FormRev. 09-24-2015 Scan and return via - Email: xxxxxxxxxxxxxxx@xxx.xxx - Fax: 000-000-0000 or - Mail: Montana-Dakota Utilities Co., Attn: Customer Support, X.X. Xxx 0000, Xxxxx, XX 00000-0000 EXHIBIT A SERVICE LOCATIONS IDENTIFICATION NUMBER (OFFICE USE ONLY) COMPLETE XXXXXX XXXXXXX XXX. XX. XXXX, XXXXX 0.
PLEASE PRINT. (* An asterisk indicates that the information is required for processing.) E-mail Address: (Enter an active e-mail address for electronic communication purposes.) Spouse/Partner Name: *Billing Address: *City: *State: _ *Zip: *Primary Contact Phone: ( ) - Cell Phone: ( ) - Fax Number: ( ) - *Emergency Contact Name: *Address: *City: _ *State: _ *Zip: *Emergency Phone Number: ( ) - Employer Name: Work Phone: ( ) - GPNG Account Holder Name Signature Date: Name that will appear on the xxxx-financially responsible person or entity FOR OFFICE USE ONLY CSA ID# Processed by: Date:
PLEASE PRINT. Participant’s Full Legal Name: Participant’s Date of Birth: Parent’s Full Legal Name: Parent’s Cell Phone Number: Signature of Participant: Signature of Parent/Legal Guardian (If participant is under the age of 18): Today’s Date: THIS IS NOT A SCHOOL DISTRICT SPONSORED EVENT
PLEASE PRINT. 2. Part 1 to be completed by patient.
PLEASE PRINT. 2. Employee completes Part A; doctor completes Part B 3. Employee to return completed form to Disability Management Coordinator, Department of Human Resources, Suite A, East Office Building, York University, 0000 Xxxxx Xxxxxx, Xxxxxxx, XX, X0X 0X0 Part A: TO BE COMPLETED BY THE EMPLOYEE Name of Employee: Home Phone Number: Home Address: Start Date of Absence from work: Department: Position: I consent to the release of the information contained on this form to my employer.
PLEASE PRINT. Groom’s/Bride’s Name Phone # Groom’s/Bride’s Name Phone # Permanent Mailing Address Date(s) of Function Location(s) Island Phone/Contact Number
PLEASE PRINT. Date Company Name: Type of Service: Personal Business Contact Name(s): Address: City/Town: Province: Postal Code: Phone Number: (Bus.) (Res.) Financial Institution (FI): FI Account Number: FI Transit Number: - (branch - 5 digits; FI - 3 digits) Address: City/Town: Province: Postal Code: Authorized Signature(s): Canadian Health Food Association Attention: Accounts Payable 000 - 000 Xxxxxxxx Xxxx. Xxxxxxx, XX, X0X 0X0
PLEASE PRINT. Identification labels must be attached securely to the back of all works. They must state the artist’s name, title of work, medium and sale price (or insurance value, if marked Not For Sale). These labels are for identification purposes only, as ESAC will provide the exhibit labels. Delivery and Return: It is the artist’s responsibility to deliver and pick up work on the dates assigned. Shipped artwork must be accompanied by return shipping labels, name of the preferred shipper and insurance. Sales: A commission of 30% of the selling price will be charged for any item sold from any exhibition sponsored by ESAC. This includes those sold within 30 days of the close of the exhibit. Removal: No work may be removed (including works sold) before the end of the exhibit, unless specifically authorized by the ESAC Director or the Exhibition Committee. Removal must be done by the artist within two days of exhibit closing. Unclaimed work after one week will become property of the ESAC.
PLEASE PRINT. Name: Date of Hire: (Last) (First) (MI) Address: Phone: (Street) (City) (State) (Zip) Position/Title: (Check One) Paraprofessional Tutor School/Work Location: I understand by electing to START Payroll Deferral I am authorizing my employer, the Amesbury School Committee, to annualize my current salary, and to pay it to me in twenty-six (26) equal installments starting with the first payroll period in the school year after which this election is made. I also understand that once I choose to START Payroll Deferral this election, which is voluntary, shall remain in effect for the entire school year, and will continue from one school year to the next, unless and until I execute another Paraprofessional Payroll Deferral Form and elect to STOP Payroll Deferral. (Signature of Employee) (Date) (Payroll Department Use Only)