PLEASE PRINT LEGIBLY. This form may only be submitted by the test center administrator, designated liaison or agency head as shown in TCLEDDS or otherwise accompanied by a memorandum on departmental letterhead to support an alternate agency representative. Any change in the testing xxxxxxx or testing administrator requires notification to BOTH TCOLE AND /PCI. For TCOLE contact Xxxxx Xxxxxx at xxxxx.xxxxxx@xxxxx.xxxxx.xxx; and “Productivity Center” (PCI) at xxxxxxx@xxxxxxx.xxx for information. Testing Center Name Testing Center ID Number Submittal Date Submitted by: [ ] Agency Head [ ] Test Center Administrator [ ] PCI Liaison / Lead Xxxxxxx First Name Last Name Phone Email Change in testing xxxxxxx information #1 (A Testing Xxxxxxx must read the Electronic Testing Manual available on the TCOLE web site.) [ ] Add [ ] Remove [ ] Info change only TCOLE PID (if applicable) First Name M.I. Last Name Suffix Mailing Address City State Zip Work Phone Cell Phone Email Change in testing xxxxxxx information #2 (A Testing Xxxxxxx must read the Electronic Testing Manual available on the TCOLE web site.) [ ] Add [ ] Remove [ ] Info change only TCOLE PID (if applicable) First Name M.I. Last Name Suffix Mailing Address City State Zip Work Phone Cell Phone Email Change in test center administrator or lead xxxxxxx information The “Testing Center Administrator” is the person designated as the liaison or point of contact between TCLEDDS/PCI and the testing center. [ ] New Administrator [ ] New Lead Xxxxxxx TCOLE PID (if applicable) First Name M.I. Last Name Suffix Mailing Address City State Zip Work Phone Cell Phone Email Change or Addition to the Testing Facility, Software or Access Security Systems, or Other Required Notifications Provide notification of changes of Training Facility name, physical address / location, mailing address or contact information. [ ] Facility/Site Change (Attach Photos for ACE Review) [ ] Software or System Access Security Change/Update [ ] Other Notification: (Specify) Primary Contact Name Phone Email Details: (Attach additional documentation pages if necessary.) By signature below I attest that the above information is true, accurate and correct and I am authorized to submit this document to TCOLE and PCI. / / (Type or Print) Name Title Signature (Typed or Electronic Not Accepted) Date Submit 1 copy via email to xxxxxxx@xxxxxxx.xxx and 1 copy via email to xxxxx.xxxxxx@xxxxx.xxxxx.xxx.
PLEASE PRINT LEGIBLY. Name: Business Name (If Applicable): Street Address: City: Telephone (Required) State: Zip Code: Home: Work: Cell: Resale Tax # (If applicable): _ Driver’s License #: Attach copy and/or fax certificate Required Email address: How did you hear about Four Seasons Auction Gallery? Please circle: Friend Flyer/Brochure Newspaper Internet Sign Other This information may be used to contact you about future auctions.
PLEASE PRINT LEGIBLY. NAME E-MAIL ADDRESS PHONE #
PLEASE PRINT LEGIBLY. Application Date: Printed Name of Applicant /Licensee Xxxxxx Island Property Address Preferred Phone Email Address BOAT (Make/Model): Length: Color: Motor: O/B I/B Marine Registration Number: Towing Vehicle Tag Number and State: Staff Use Only PBL: Decal # Fobs # *Decal must be placed on the tongue of the boat trailer to either side of the winch. Paid $100 New Membership Fee Staff Member verified decal is affixed to trailer RULES AND REGULATIONS
PLEASE PRINT LEGIBLY. This is to certify that I, am a student worker or a volunteer in the department of I further certify that I have completed the campus Data Security & Privacy training and provided my department with a certificate of completion. Due to the nature of my assigned duties and responsibilities, I am aware that I have access to confidential materials in campus information systems. I understand that I am required to treat such data in a confidential and professional manner and that any breach of confidentiality or abuse of my access may result in disciplinary action, and other legal proceedings. I understand that I may not under any circumstances, share my account access, give my account information to any one else to obtain access, divulge information in relation to the data, or use the data in any way other than what has been clearly defined by my position. Signature: Date:
PLEASE PRINT LEGIBLY. Upon your death, this is the person who will receive a monthly benefit for life based on the joint-survivor option you select. A beneficiary must be named for FPPA to calculate your retirement benefit survivor options. After a benefit option has been selected and the first pension payment has been deposited or otherwise negotiated, you may only change your beneficiary for your defined benefit pension in the event of a change in your marital or civil union status or the death of your named beneficiary. In the event of a change in beneficiary the pension benefits payable will be recalculated according to your life expectancy and that of your newly named beneficiary. If you select Normal Option, no monthly benefit will be paid upon your death and your primary beneficiary named here becomes the person to receive a refund of any remaining contributions not paid to you in monthly benefits. NOTE: Please contact Fidelity to designate a beneficiary for your DROP account if applicable. PRIMARY BENEFICIARY Only ONE person can be named as primary beneficiary. Beneficiary’s Last Name First Name Middle Initial ( ) - - Mailing Address Apt. # Home Phone Number ( ) - - City State Zip Work Phone Number / / Social Security Number / / Date of Birth (mo/day/yr) Female Male Relationship of Beneficiary to Applicant If spouse, check which applies: marriage civil union / / Applicant's Full Legal Signature Date REFUND ONLY - BENEFICIARY OR ESTATE OR TRUST Xxxx only ONE box below. This section applies only to a one-time refund of remaining member contributions not paid out in monthly pension benefits and only when there is no primary beneficiary payable. No monthly pension benefit would be paid to the beneficia- xxxx listed below. Any previously elected Beneficiary-Refund Only or Estate or Trust is revoked. No Designated Refund Only Beneficiary OR Estate OR Trust is elected The following Trust is elected to receive a refund of remaining member contributions, if any. Name of Trust I elect my Estate to receive a refund of remaining member contributions, if any. On the next page the following are named as Refund Only Beneficiaries to receive a refund of remaining member contributions, if any. PART D - DESIGNATED BENEFICIARY FOR FPPA DEFINED BENEFIT SYSTEM - continued - If you have more than three Refund Only Beneficiaries, attach a page and xxxx the following box. I have attached a page. Name - - Relationship Social Security Number Date of Birth Phone Number Percent of Assets % Email A...
PLEASE PRINT LEGIBLY. Participant’s Name Age Guardian Name Date Guardian’s Signature Phone 1 Email Phone 2 In Emergency Notify Phone Must be returned with back page completed CANYON CREEK COMPLEX WAIVER OF LIABILITY / RELEASE OF CLAIMS / CONSENT TO USE OF IMAGES Event: All It Takes 7th Grade Leadership Training Canyon Creek Camp Weekend (the “Event”) Dates of Event: October 1-3, 2018 Camper’s / Child Participant's Name(s): (hereafter “Camper”) The undersigned warrants and represents that he/she is a parent or legal guardian of Camper and that the undersigned possesses the authority to execute this Waiver of Liability/Release of Claims on behalf of Camper. The undersigned acknowledges that while at Canyon Creek Complex ("Camp") and participating in the Event, the Camper may or will be participating in sporting and recreational activities including without limitation, ropes courses, climbing walls, trapeze leap, football, basketball, soccer, hockey, baseball, golf, volleyball, tennis, dodgeball, archery, swimming and other water sports and other sports and activities (collectively, “Camp Activities”). I understand that many of these activities may involve a high degree of risk of injury to the Camper. The undersigned acknowledges that he/she has been advised that the Camper should be evaluated by his/her physician prior to participating in Camp Activities. The undersigned further acknowledges and agrees that Canyon Creek Sports Camp, Canyon Creek Properties, LLC and Canyon Creek Holdings, LLC and the individual organizers and directors of the Event and all owners, officers, directors, members, partners, employees, agents, affiliates and representatives of the foregoing (collectively, "Personnel") will not be responsible or liable for any injuries, claims, liabilities or damages of any kind which are sustained, suffered or incurred by the Camper as a result of (a) his/her or their participation in Camp Activities or in the Event or attendance at Camp and (b) the negligence of any Personnel. In consideration of the Camper's voluntary participation in Camp Activities and in the Event, to the extent permitted by law, the undersigned, on behalf of the Camper and for the Camper's heirs, executors, distributees, guardians, legal representatives, administrators and assigns, hereby RELEASES, WAIVES, DISCHARGES AND HOLDS HARMLESS all Personnel from and against any and all injury, disability of death, loss or damage to person or property, and all claims, damages, liabilities, losses, costs,...
PLEASE PRINT LEGIBLY. Player Name Address City State Zip Code Age E-mail Home Phone Cell Phone Insurance Company Policy Number Parent or Guardian Signature Session Attending: February 8, 2014* — Ages 12-18 (Check one): ❑ Morning-$30 ❑ Afternoon-$30 Position – For Morning session only (Check one): ❑ Pitcher ❑ Catcher ❑ Infield *Choose one position for morning session. February 15, 2014* — Ages 7-11 (Check one): ❑ Morning-$30 ❑ Afternoon-$30 Position – For Morning session only (Check one): ❑ Pitcher ❑ Infield *Choose one position for morning session. Total amount due $ Fill out this form on both sides and return by Feb. 4, (with check payable to Loras College Baseball) to: LORAS COLLEGE BASEBALL, Mail #154
PLEASE PRINT LEGIBLY. Select one: ❑ All Day Camp ❑ Junior Duhawk Camp Name: Address: City: State: Zip: Date of Birth: / / Gender (mark one): Male Female Grade 2016-2017 academic year: Home Phone: E-mail: (need for confirmation) School: T-shirt (circle one): YS YM YL S M L XL Experience: ❑ Developmental ❑ AYSO ❑ CLUB ❑ KEY CITY SOCCER Team Name (if playing club soccer): If there are any specific medical situations that should be known or activities that should be restricted, contact the camp by attaching the information with this applica- tion or by calling the Camp Director at (000) 000-0000.
PLEASE PRINT LEGIBLY. This information will be used for background screening purposes only and will not be used for any other purpose Last Name: First Name: Middle: Other Names/Alias: Social Security #: Date of Birth (MM/DD/YYYY): Driver’s License #: State of Driver’s License: Present Address: Phone: City: State: Zip: Email Address: All Previous Addresses in the Last Seven (7) Years Signature: Date:
