Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: *********************************************************************************** High School Program Teacher: Please initial and indicate by marking an “X” in the box(s) for the course or courses you recommend this student be given credit for or for which you encourage proficiency testing. Students must earn at least a “B” to be given credit. Student is only eligible to earn “up to 12 articulated credits.” Sign and mail to: Xxxxxx X. XxXxxxx Xxxxx State College 0000 Xxxxx Xxxxxx NW North Canton, Ohio 44720 High School Program Teacher Initials Xxxxx State College (SSC) Course Number Xxxxx State College (SSC) Course Title SSC Credit Hours High School Grade AUT122 Automotive System & Engine Tech 4 High School Program Teacher’s Approval: Date: ********************************************************************************************
Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: *********************************************************************************** High School Program Teacher: Please initial and indicate by marking an “X” in the box(s) for the course or courses you recommend this student be given credit for or for which you encourage proficiency testing. Students must earn at least a “B” to be given credit. Student is only eligible to earn “up to 12 articulated credits.” Sign and mail to:
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 Form – Rev. 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. DATE APPLICANT'S NAME CO-APPLICANT'S NAME CURRENT BILLING ADDRESS: FUTURE BILLING ADDRESS: PHONE NUMBER - Home ( ) - Work ( ) - PROOF OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include name of road, subdivision with lot and block number) PREVIOUS OWNER'S NAME AND ADDRESS (if transferring Membership) ACREAGE HOUSEHOLD SIZE NUMBER IN FAMILY LIVESTOCK & NUMBER SPECIAL SERVICE NEEDS OF APPLICANT The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. | NOTE: FORM MUST BE COMPLETED BY APPLICANT ONLY. A MAP OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the laws of the State of Texas (hereinafter called the Corporation) and (hereinafter called the Applicant and/or Member), Witnesseth: The Corporation shall sell and deliver water water service to the Applicant and the Applicant shall purchase, receive, and/or reserve service from the Corporation in accordance with the bylaws and tariff of the Corporation as amended from time to time by the Board of Directors of the Corporation. Upon compliance with said policies, including payment of a Membership Fee, the Applicant qualifies for Membership as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth therein, a copy of which has been provided as an information packet, for which Member acknowledges receipt hereof by execution of this agreement. A copy of this agreement shall be executed before service may be provided to the Applicant. The Board of Directors shall have the authority to discontinue servic...
Please Print. Name of purchaser Business Address City State Zip Code Purchaser’s Tax ID Number State of Issue Country of Issue If no Tax ID Number | FEIN | Driver’s License Number/State Issued ID Number | Foreign diplomat number Enter one of the following: | | |
Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: ********************************************************************************** *
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. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: *********************************************************************************** High School Program Teacher: Please initial and indicate by marking an “X” in the box(s) for the course or courses you recommend this student be given credit for or for which you encourage proficiency testing. Students must earn at least a “B” to be given credit. Student is only eligible to earn “up to 12 articulated credits.” Sign and mail to: Xxxxxx X. XxXxxxx Xxxxx State College 0000 Xxxxx Xxxxxx NW North Canton, Ohio 44720 High School Program Teacher Initials Xxxxx State College (SSC) Course Number Xxxxx State College (SSC) Course Title SSC Credit Hours High School Grade DAS121 Dental Assisting Techniques I 3 DAS122 Dental Assisting Radiography 2 DAS123 Dental Assisting Techniques II 3 DAS124 Dental Assisting Materials 2 High School Program Teacher’s Approval: Date: ********************************************************************************************
Please Print. Date Requested Type of Event Event Start time Event End Time Time should include set up and clean up. Applicant Name Address CITY/STATE/ZIP Employment Address Home phone Business Phone Cell phone Group or Organization and Address Number of Guests Attending Will Alcohol be served, brought, or distributed at the event ? Off-Duty Officer is needed for alcohol on premises! Officer must be paid “IN CASH” before the event begins. The fee of $38.00 per hour will be paid by the renter. Officer needed Start time: End time: Reservations must be made by persons 21 years of age or older.
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
