Tax I.D. No. insert the tax identification number of the vendor that appears in the preceding column
Tax I.D. For the purpose of this Provider Agreement, the term “Parties” may be used to collectively refer to both ODH and Provider. In order to be valid, this Provider Agreement must be signed by Provider and returned to ODH, at the above address. PROVIDER AGREEMENT TERM. 11/01/2019 “Agreement Beginning Date” shall be defined as the date indicated here, or the date of execution by both Parties, whichever is later: 06/30/2026 “Agreement Ending Date” shall be defined as the date indicated here, or the date of termination, whichever is first: This Agreement is in effect from the Agreement Beginning Date through the Agreement Ending Date, unless this Agreement is renewed or terminated pursuant to the provisions of this Agreement prior to the termination date.
Tax I.D. No.: ------------------------------------- ----------------------------------- Signature Advisor (if applicable): ------------------------------------- ----------------------------------- Name of Seller Custodian: ------------------------------------- ----------------------------------- Name and Title of Signatory (if applicable) Account No.: Address: ----------------------------------- ------------------------------------- ------------------------------------- Dated: IMPORTANT - READ CAREFULLY The SIGNATURE GUARANTEED BY: signature(s) to this Certification must correspond with the name(s) as written upon the face of this certificate(s) or Sign here__________________________ bond(s) in every particular without alteration or enlargement or any change whatever. Signature guarantee should be made by a member or member organization of the New York Stock Exchange, members of other Exchanges having signatures on ___________________________________ file with transfer agent or by a (PERSON(S) EXECUTING THE POWER commercial bank or trust company having SIGN(S) HERE) its principal office or correspondent in the City of New York EXHIBIT "F" RULE 904 OFFSHORE RESALE BROKER CERTIFICATION [DATE] The undersigned is the authorized broker appointed by ___________ (the "Seller") to handle the offshore resale of _________ shares of Common Stock (the "Shares"), of Pacific Energy Resources Ltd. (the "Corporation"), beneficially owned by the Seller and represented by stock certificate number _____. The Seller has instructed the undersigned to resell the Shares in, on or through the facilities of the Toronto Stock Exchange (the "Resale") in accordance with Rule 904 of Regulation S ("Regulation S") under the United States Securities Act of 1933, as amended (the "Securities Act"). The Seller has advised the undersigned of the following: The Seller is the beneficial owner of the Shares, having acquired and fully paid for the Shares by purchase of the Shares on [date]. The Seller wishes to sell the Shares in, on or through the facilities of the Toronto Stock Exchange in accordance with Rule 904 of Regulation S. The undersigned desires to effectuate the Resale in, on or through the facilities of the Toronto Stock Exchange, and as a condition thereto, hereby certifies to the Corporation, [name of law firm], and the custodian, if applicable, who has custody of the Shares (the "Custodian"), as follows:
Tax I.D. Number WN-822-569000-000 PARCEL 40 - 41 ALL THAT CERTAIN piece or parcel of land situate in Warren Borough, Xxxxxx County, Pennsylvania, bounded and described as follows: BEGINNING at the corner of lands formerly sold to Xxxx Xxxxxx in the public road leading from Xxxxxx to Glade Run, now Pennsylvania Avenue East; thence easterly along said public road one hundred eighteen (118) feet to the corner of lands of United Refining Company; thence south 51 degrees 44’ west One hundred sixty-six (166) feet, more or less to a post; thence north 38 degrees 16 minutes west one hundred eighteen (118) feet to a point in the line of Marrer Street; thence north 51 degrees 44 minutes east one hundred sixty six (166) feet, more or less to the place of beginning. DEED Reference: Liber 353, page 1095. Tax I.D. Number WN-822-963800-000 PARCEL 39 - 40
Tax I.D. 9.01 BIDDER to enter federal tax id number on PennBid where requested. WATER SYSTEM INTERCONNECT
Tax I.D. The Administrative Agent shall have received the tax identification or social security number of each Borrower.
Tax I.D. The Tax ID for your organization. 0000 Xxxx Xxxx Blvd, Xxxx XX, Suite 310, Raleigh, NC 27607 An Affiliated Practice Providing Outside Agency Request Form Send completed form to: xxx@xxxxxxxxxxxxxx.xxx or Fax: 252‐000-0000 Please fill in the information below, ALL FIELDS MUST BE COMPLETED. Once received and approved you may contact the appropriate Affordable Dentures to schedule an appointment. Approvals may take up to 48 hours. Please check the appropriate box indicating whether your organization would like to be billed or would prefer to send a check with the patient. Please bill my organization A check will be sent with the patient. Name of Organization: Billing Address: Contact Person: E‐Mail (required): Telephone: Fax: This form will be valid from: to Patient’s Name: Affordable Dentures Office to Visit: Amount Not to Exceed: (must be completed) $ Service(s) Patient needs: Authorized Signature: Tax ID: Affordable Care, Inc. 0000 Xxxx Xxxx Blvd, Xxxx XX, Suite 310, Raleigh, NC 27607 xxx.xxxxxxxxxxxxxxxxxx.xxx OA Account Number:
Tax I.D. No.: ______________________________________ -------------------------------- FORM OF ASSIGNMENT (To be signed only on transfer of Warrant) For value received, the undersigned hereby sells, assigns, and transfers unto ____________________________________ the right represented by the within Warrant to purchase shares of Common Stock of Public Online Communications Corporation to which the within Warrant relates, and appoints ______________________________ Attorney to transfer such right on the books of Public Online Communications Corporation, with full power of substitution in the premises.
Tax I.D. License ID #: TN0504T0791 Tenant ID #:T079 EXHIBIT A SITE LICENSE This Site License to the Master License Agreement dated December 31, 1998 ("Agreement"), between SIGNAL ONE, LLC ("Licensor") and TRITEL COMMUNICATIONS, INC. ("Licensee") is executed this ____ day of March, 1999. This License Supersedes all previous Agreements, both verbal and written between the parties for this Site.
Tax I.D. The Service Provider’s federal employer I.D. number or social security number is as follows: [ ].
