PLEASE PROVIDE THE FOLLOWING INFORMATION. 1. (a) Name of Preferred Stock Holder: _____________________________________________________
PLEASE PROVIDE THE FOLLOWING INFORMATION. Creditor's telephone number Creditor's e-mail address
PLEASE PROVIDE THE FOLLOWING INFORMATION. Transportation Type to Be Used Student Covered by Auto Insurance yes no Name of Auto Insurance Company Auto Insurance Company Address Policy Number Agent Name Phone Student Covered by Medical Insurance yes no Name of Medical Insurance Company Medical Insurance Company Address Policy Number Agent Name Phone Students are accepted and placed without regard to age, disability, national origin, race, marital status, parental status, religion or gender. Student Name (print) Student Signature and Date Parent/guardian Name (print) Parent/guardian Signature and Date Business Site Supervisor Name and Phone (print) Business Site Supervisor Signature and Date Business Insurance Information Insurance Company Insurance Company Address Agent Name Phone Number General Liability Policy Number
PLEASE PROVIDE THE FOLLOWING INFORMATION. I AM WILLING TO WORK FULL-TIME (except for regularly scheduled days off) UNTIL THE FINAL DAY OF BEACH PATROL FOR THE 2016 SEASON (Sunday, September 25, 2016). I am requesting permission to be considered to continue my employment with the Ocean City Beach Patrol past Monday, September 5, 2016 (Labor Day) and understand that my evaluations and employment record will be used to determine if I will be granted permission to continue employment. If selected I will work on the days that I have indicated below. I understand that this is for the remainder of the Summer of 2016 season. I am aware that this is an extension of my current position with the Ocean City Beach Patrol and therefore will be compensated at my current rate. Additionally, I appreciate that the Beach Patrol takes into account where I would like to be placed when I work, but understand that I will be placed where needed which may include being moved during the course of a day. Furthermore, I realize that it is my responsibility to provide a schedule indicating my availability for work and have done so by circling the dates below. I also understand that should I need to change the schedule that I have provided, I must complete a “Special Request Day Off” form and forward it to Lt. Xxxxx at least two full weeks prior to the requested days off. Initials (Please one box) I will be working Sunday, September 25, 2016 YES or NO (Please one box) I am interested in working after September 25, 2016 YES or NO (Please one box) I am interested in working Full-time until October 10, 2016 YES or NO I WILL WORK FULL-TIME (except for regularly scheduled days off) UNTIL MY FINAL DAY OF BEACH PATROL FOR THE 2016 SEASON WHICH IS Choose day , Choose Month , 2016. DAY OF WEEK MONTH DATE NOTE: If concluding employment prior to September 25, 2016, you are required to submit official documentation if it is not already on file. I have provided official documentation of my last day of full-time employment. YES NO WAS THIS DATE INDICATED ON THE CONTRACT YOU SIGNED WITH THE BEACH PATROL? YES NO IF NOT, PLEASE EXPLAIN This date should not vary from the date you indicated when you completed your employment agreement. If it does it may affect your eligibility for employment or promotions in the future (Full Documentation Required) YOU SHOULD BE GIVING THE BEACH PATROL EVERY POSSIBLE DAY! DATE and TIME WHEN TURNING IN EQUIPMENT / /2016 : DATE WHEN LEAVING OCEAN CITY / /2016 IS YOUR EXITING RELATED TO SCHO...
PLEASE PROVIDE THE FOLLOWING INFORMATION. Initials I WILL WORK FULL-TIME (except for regularly scheduled days off) UNTIL THE FINAL DAY OF BEACH PATROL FOR THE 2011 SEASON (Sunday, September 25, 2011). ❒ I WILL WORK FULL-TIME (except for regularly scheduled days off) UNTIL MY FINAL DAY OF BEACH PATROL FOR THE 2011 SEASON WHICH IS , , 2011. DAY OF WEEK MONTH DATE ❒ I WILL ONLY BE AVAILABLE TO WORK ON THE FOLLOWING DATES UNTIL THE FINAL DAY OF BEACH PATROL FOR THE 2010 SEASON (Sunday, September 25, 2011).
PLEASE PROVIDE THE FOLLOWING INFORMATION. Name - Last First Home Address (Number, Street, Apt.) City State Zip Occupation ( ) ( ) Home Phone Work Phone E-mail - - 🞏 Male 🞏 Female Birthday Sex Highest level of education completed: 🞏 High School 🞏 A.A. 🞏 B.A/B.S. 🞏 M.A./M.S. 🞏 Ph.D. 🞏 Trade School/Other 🞏 Some College COURSE INFORMATION 5-DIGIT COURSE CODE COURSE TITLE DATES 23S EDU 183 01 Keeping the Dream Alive Conference 3/10/23 - 3/11/23 PAYMENT �� Check - payable to CSUS College of Continuing Education 🞏 Visa 🞏 Master Card 🞏 Discover Card Number Expiration Date Amount Name of Cardholder Cardholder’s Signature
PLEASE PROVIDE THE FOLLOWING INFORMATION. Transportation Type to Be Used Student Covered by Auto Insurance yes no Name of Auto Insurance Company Auto Insurance Company Address Policy Number Agent Name Phone Student Covered by Medical Insurance yes no Name of Medical Insurance Company Medical Insurance Company Address Policy Number Agent Name Phone Students are accepted and placed without regard to age, disability, national origin, race, marital status, parental status, religion or gender. Today's Date Shadow for Semester 1 Shadow for Semester 2 Student Name (print) Student Signature and Date Parent/guardian Name (print) Parent/guardian Signature and Date
PLEASE PROVIDE THE FOLLOWING INFORMATION. [Response Field:] Street Address: [Response Field:] State, Zip Code: [Response Field:] Email:1
PLEASE PROVIDE THE FOLLOWING INFORMATION. Name - Last First Home Address (Number, Street, Apt.) City State Zip Occupation ( ) ( ) Home Phone Work Phone E-mail - - 🞏 Male 🞏 Female Birthday Sex Highest level of education completed: 🞏 High School 🞏 A.A. 🞏 B.A/B.S. 🞏 M.A./M.S. 🞏 Ph.D. 🞏 Trade School/Other 🞏 Some College COURSE INFORMATION 5-DIGIT COURSE CODE COURSE TITLE DATES 22F EDU 870B 01 California Mathematics Council North: Annual Conf. 12/2/2022 - 12/4/2022 PAYMENT �� Check - payable to CSUS College of Continuing Education 🞏 Visa 🞏 Master Card 🞏 Discover Card Number Expiration Date Amount Name of Cardholder Cardholder’s Signature
PLEASE PROVIDE THE FOLLOWING INFORMATION. Room Preference □ Single Bedroom □ Double Bedroom Session Preference □ Session I (May 10 – May 31) □ Session III (July 1 – July 31) □ Session II (June 1 – June 30) □ Session IV (May 11 – August 19) Refund, Location, and Special Condition: Refund may be obtained on a session if cancelation notice is received prior to the second day of that Session. No refunds will be granted after the second day of a session for that session. Payment will ensure placement in a double or single occupancy room in Apartments on a first come first serve basis. Early move in will begin August 13 - August 20, 2021. Physical/Medical Conditions: List any physical/medical conditions that should be considered in making a hall/room or board assignment or that might be necessary to know in case of emergency. To be considered for physical or medical accommodations, prior notification is necessary to meet your individual needs. Medical verification may be required.
