Signature of Applicant. Membership dues are not tax-deductible as charitable contributions. The dues include a subscription to either FarmWeek or Partners publication ($3.00) and to the county Farm Bureau publication (in those counties where applicable). The cost of the subscriptions cannot be deducted from the membership dues.
Signature of Applicant. Return to: Office of the Village Clerk Village of Ashwaubenon 0000 Xxxxxxxx Xxx Ashwaubenon, WI 54304 (000)000-0000 [ ] Approved [ ] Denied – Reason:
Signature of Applicant. (If the application is an organization or group, attach documentation showing that the person executing this application has authority represent the sponsoring organization or group.) NOTICE: NO VEHICLES WILL BE PERMITTED ON THE PLAZA FOR ANY PURPOSE INCLUDING MANEUVERING, LOADING AND UNLOADING. REVIEWED AND APPROVED: Marketing & Events Manager Xxxxxx Xxxxx Park MB Real Estate Services, INC DATE: O F F I C E U S E O N L Y • ( ) Signatures • ( ) Reimbursement Agreement • ( ) Certificate(s) of Insurance • ( ) Lay-out or Diagram Received by: Date: FEES Fee Rate Photography Fee $6,000 (Per Day) or $500/hour Reimbursement Fees Rate Custodian Service $17.75 Per Hour (Straight Time) Electrician Service $150.50 Per Hour (Straight Time) Security Service $20.80 Per Hour (Straight Time) NOTES ((PLEASE READ)):
Signature of Applicant. Date: Parental Permission for Minors (for applicants under 18 years of age) My daughter/son has permission to participate in a UW Medicine observational experience and I authorize UW Medicine to administer a Tuberculosis test as deemed necessary. I understand the above statements and verify the information is accurate and complete.
Signature of Applicant. As the services of a qualified witness cannot be provided at lodgment, the statutory declaration should be signed and witnessed prior to lodgment. ** If made outside NSW, cross out witness certification. If made in NSW, cross out the text which does not apply. * s117 RP Act requires that you must have known the signatory for more than 12 months or have sighted identifying documentation. Annexure A This and the following pages constitute Annexure A of the Lease made between XXXXX XXXXX COUNCIL ABN 14 472 131 473 (Landlord) and THE TECHNICAL AND FURTHER EDUCATION COMMISSION ABN 89 755 348 137 (Tenant). Date: We certify this dealing correct for the purposes of the Real Property Xxx 0000. EXECUTED by XXXXX XXXXX COUNCIL ABN 14 472 131 473 by its authorised officer in the presence of: Signature of Witness Signature of authorised officer Name of Witness Name of authorised officer Address of Witness Position of authorised officer EXECUTED by THE TECHNICAL AND FURTHER EDUCATION COMMISSION by its delegate (but not so as to incur any personal liability) in the presence of: Signature of Witness Signature of Delegate Name of Witness Name of Delegate Address of Witness Position of Delegate COMMERCIAL TERMS SCHEDULE Term Meaning of term Landlord XXXXX XXXXX COUNCIL ABN 14 472 131 473 of 00 Xxxxxxx Xxxxxx, Xxxxxxxxxxx, XXX, 0000 and its successors and assigns Tenant THE TECHNICAL AND FURTHER EDUCATION COMMISSION ABN 89 755 348 137 of Xxxxx 0, Xxxxxxxx X, 00 Xxxx Xxx Street, Ultimo NSW 2007 and its successors and permitted assigns Land Lot [ ] in Deposited Plan [ ]. Improvements The Connected Learning Centre building, structure and other improvements on the Land at the Commencing Date as modified and extended from time to time. Premises The Land Term 10 years from [ ] (Commencing Date) to [ ] (Terminating Date) Further Term 5 years commencing on the day after the Terminating Date Second Further Term 5 years commencing on the day after the terminating date of the Further Term Base Rent $382,800.00 per year CPI Review Date On each anniversary of the Commencing Date Permitted Use Learning centre, training, education, community events and ancillary activities including offices or uses otherwise consistent with the functions and objectives of the Tenant in accordance with the Technical and Further Education Commission Xxx 0000 Table of Contents PART TITLE PAGE NO COMMERCIAL TERMS SCHEDULE 4 1. DEFINITIONS AND INTERPRETATIONS 6 2. TERM AND FURTHER TERMS 12 3. RENT 12 4. OUTGOIN...
Signature of Applicant. FULL ADDRESS CITY STATE ZIP Bar Card Number NOTED APPLICANT [IS] [IS NOT] A MEMBER OF THE DALLAS COUNTY CRIMINAL BAR ASSOCIATION. DATE APPROVED: , 20 .
Signature of Applicant. Date: ------------------------------------------------------------OFFICE USE ONLY------------------------------------------------------------ Date Received Time Received Staff Initial □ Approved □ Denied Supervisor’s Approval: □ Approved □ Denied Director’s Approval: City of Rosemead • Parks and Recreation Department FACILITY FEE SCHEDULE Name: Organization: Address: City: Zip: Home Telephone: Cell: ROSEMEAD AQUATIC CENTER Location Area (Capacity) Resident Non-Resident Total Pool Facility (picnic area excluded) (500) $ 75/hr $ 150/hr $ Exclusive Party Includes full canopy (350) $ 175/hr $ 350/hr $ Covered Picnic Area (1/2 Canopy) or Lights * Canopy 1 or 2 (100)$ $35/hr $ 600/hr $ BBQ rental minimum 2 hours $ 30/hr $ 30/hr $ Lawn Area (picnic) * (100) $ 35/hr $ 60/hr $ Lifeguard Minimum 5-6 (100) $ 20/hr $20/hr $ Shelter Deposit $ 50 $ 150 $ Security Deposit $ 300 $ 500 $ SPLASH ZONE Location Area (Capacity) Fee Total Exclusive Party Includes large shelter (350) $140/hr $140/hr $ Small Shade Shelter * (36) $ 40/hr $40/hr $ Large Shade Shelter * (70) $ 50/hr $50/hr $ BBQ rental Minimum 2 hours $ 30/hr $30/hr $ Aquatic Staff Minimum 4-6 $ 20/hr $20/hr $ Shelter Deposit $ 50 $50/hr $ Security Deposit $ 300 $300/hr $ Class III Total Special Event Insurance 1-100 = $215 / $000 000-000 = $360 / $000 000-0000 = $475 / $525 $ * These areas are only available during regular recreational swim hours, must be rented for the entire duration of the recreation swim, and entrance fees must be paid for ALL in attendance. TOTAL FACILITY FEES DUE $ (This section to be filled out by staff) Deposit submitted $ on date Received by Rental fees paid $ on date Received by If Event Insurance required, copy of certificate received on date in the amount of $ Deposit refund of $ approved on date by City of Rosemead • Parks and Recreation Department SPLASH ZONE FACILITY CLEAN-UP CHECKLIST ROSEMEAD AQUATIC CENTER Name of Applicant: Date of Event: Facility/Room Used: Start Time: End Time: OFFICE USE ONLY ROOM/AREA CONDITION/COMMENTS Tables and chairs wiped down Pool Splash Pad Slides All trash to be bagged at the end of the party. Staff will remove trash. Decorations removed Equipment removed Restrooms – clean and free of debris Other (specify): Additional Comments: Signature of Staff Member: Date: Signature of Applicant: Date: Recommendation for Refund: □ Yes □ No City of Rosemead • Parks and Recreation Department CANCELLATION POLICY
Signature of Applicant. Date ____________ Insurance Requirements The User shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property that may arise from or in connection with the use of the Premises. The Village Green Metropolitan Park District shall be named as an additional insured on User’s General Liability insurance policy. The General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $1,000,000 general aggregate. The insurance policy shall contain, or be endorsed to contain that the User’s insurance coverage shall be primary insurance as respect to the Entity. Any insurance, self-insurance, or insurance pool coverage maintained by the Entity shall be excess of the Lessee’s insurance and shall not contribute with it. The User shall provide a certificate of insurance evidencing the required insurance before using the Premises.
Signature of Applicant. Date: To Be Completed by Administrative Xxxx or Student Advisor of Extern’s Parent Institution I certify that the student in question, who has requested to participate in the above-mentioned externship, is doing so with the knowledge and permission of our institution. I certify that this student is in good academic and professional standing at his/her institution. Signature of Xxxx/Student Advisor: Date: To Be Completed by Supervisor at The Ohio State University During this student’s anesthesiology externship at the Ohio State University College of Dentistry, he/she will be under the direct supervision of the full-time faculty in the Department. This student will not be asked to perform any activities during which he/she is not directly supervised. The anesthesiology faculty at the College of Dentistry will be responsible for the extern’s supervision and will provide a written evaluation of this student’s performance upon request. The student will be required to keep a written log of activity while participating in this externship and the accuracy of this log will be verified by the extern’s supervisor.
Signature of Applicant. NOTICE: This form must be signed in duplicate. The Company and the Applicant should keep a signed copy. If a prepayment is made other than on the date of Part 1 of the Application, an Insurability Statement (Form NEV APP-26) is required.
