Request Type. Add access for new employee/third-party vendor Delete access for existing employee/third-party vendor Change access for existing employee/third-party vendor Name change for existing employee/third-party vendor Former name: Employee/Vendor Information Read Page 2 and complete information below. I have read the provisions set forth on Page 2 of this form. I understand that Wisconsin Statutes, § 943.70 provide criminal penalties for offenses against computer data and programs. Violation of this provision will result in termination of my online access to member accounts and/or termination of my employer’s online access to member accounts. Employee name (first, middle, last) Vendor name (if applicable) Work address IAM login ID Check here if you do not currently have an IAM login Work email address Employee or vendor signature Work telephone ( ) Date (MM/DD/CCYY)
Request Type. I am establishing a new Fidelity Advisor SIMPLE IRA Plan. (Complete all sections below in full.) I am requesting change(s) be made to my Employer information for the existing Fidelity Advisor SIMPLE IRA Plan. (Indicate the changes requested by checking the boxes below and completing the appropriate section with the new information.) Company Name* Phone Number Tax Identification Number* Employer or Payroll Contact Name Address Change Banking Information * This change will constitute an amendment to your Plan.
Request Type. New Setup ☐ Cancellation ☐ Change of Information ☐ Request Date: _ mm/dd/yy Supplier Information: Supplier Name: Alternate Name (dba name, if applicable): Supplier Address*: Street Address: City, Province: Postal Code: Contact Name: Phone Number: Remittance Email**: * If multiple locations exist, please provide an appended list of all such locations this bank information applies to. ** The Remittance email providing the applicable payment details will be sent for each EFT. Banking Information (please complete below and/or attach a voided cheque): Institution Details: Institution Name: Branch Address, City Province, Postal: For Office Use Only: D ate Received: E ntity: Entered By/Date: A pproved By/Date: How to find your banking information on a cheque: Account Details: Name on Account: Address on Account: Same as Supplier? ☐ City, Province on Account: Postal Code on Account: Institution Number: Type of Account: Business ☐ Personal ☐ Transit Number: Account Number: Authorization: I (we) hereby authorize YSS Corp. and its affiliates (“YSS”) to direct payments electronically to the bank account specified here. I (we) acknowledge that the origination of the EFT transactions to my (our) account must comply with the provisions of Canadian law. This authorization agreement is effective as of the effective date above and is to remain in full force and effect until YSS has received notification of its termination. I (we) agree to submit an updated EFT Authorization Agreement Form to YSS for the cancellation of this agreement or to make any changes to the information provided within this agreement. Authorized Signature(s): Signature: Printed Name, Title: Date: _ Signature: Printed Name, Title: Date: _
Request Type. □ Add New User □ Modify/Reinstate Existing User □ Deactivate Existing User
Request Type. New Agreement, Renewal Agreement, Update Agreement (circle/highlight one) Contact Person: Name Title Street City/State/Zip Send Via: Email or Mail Circle One Justification: Email Clinical Education Approved: Placement Coordinator/Field Disapproved: Placement Coordinator: Dept/Program Approved: Chair: Date Date Date
