TO BE COMPLETED BY. Home School Academic Advisor Please list the student's approved program applicable courses that are being completed at the host school: Course # Course Title # of Cr/Qtr Hrs. Academic Advisor Signature: Date: Print Name & Title of Advisor: Date: Email/Phone:
TO BE COMPLETED BY. PURCHASER IF (a) ABOVE IS CHECKED The undersigned represents and warrants that it is purchasing this Security for its own account or an account with respect to which it exercises sole investment discretion and that it and any such account is a "qualified institutional buyer" within the meaning of Rule 144A under the Securities Act and is aware that the sale to it is being made in reliance on Rule 144A and acknowledges that it has received such information regarding the Company as the undersigned has requested pursuant to Rule 144A or has determined not to request such information and that it is aware that the transferor is relying upon the undersigned's foregoing representations in order to claim the exemption from registration provided by Rule 144A. Dated: ------------------------ ---------------------------------------------- NOTICE: To be executed by an executive officer
TO BE COMPLETED BY. 1. Australian Borrower acquires all of the shares in CFG (other than those held by WRC) pursuant to and in accordance with the CFG Share Sale Agreement. 5 Business Days after Financial Close
TO BE COMPLETED BY. STATION ONLY Ad submitted to station? ✔ Yes No Date ad received: 7-10-20 Note: Must have separate PB-19 forms for each version of the ad (i.e., for every ad with differing copy). If only one officer, executive committee member or director is listed above, station should ask the advertiser/sponsor in writing if there are any other officers, executive committee members or directors, maintain records of inquiry and update this form if additional officers, members or directors are provided. Disposition: ✔ Accepted Accepted IN PART (e.g., ad not received to determine content)* Rejected – provide reason: *Upload partially accepted form, then promptly upload updated final form when complete. Date and nature of follow-ups, if any: Contract #: Station Call Letters: SYS 3267 Date Received/Requested: 7.10.20 Est. #: Station Location: ATLANTA GA Run Start and End Dates: 7.13-11.3.20 For national issue ads only (not required for state/local issue ads):
TO BE COMPLETED BY. THE NORTHERN HEALTH AUTHORITY This Certificate is requested by and issued to: Authority’s Contact Person Name and Title: Contract #: Phone #: Fax #: Address: Postal Code: Contractor Name Contractor Address Postal Code: PART 2 TO BE COMPLETED BY THE CONTRACTOR’S AGENT OR BROKER And certifies that policies of insurance as herein described have been issued to the insured(s) named below and are in full force and effect as of the effective date of the agreement. Insured Name: Address: Operations Insured: Type of Insurance Company Name and Policy Number Expiry Date (yyyy/mm/dd) Limit of Liability/Amount Comprehensive/ Commercial General Liability Inclusive Limits $ Automobile Liability (Owned or Leased Vehicles) Primary Excess $ $ Umbrella Liability Limits Excess of $ $ Professional Liability Limits $ Property Details $ $ Other Details $ $ These policies comply with the insurance requirements of the governing contract with the Northern Health Authority. It is understood and agreed that where required by the governing contract, the Northern Health Authority has been added as an additional insured and that thirty (30) days’ notice of any material change or cancellation of any of the policies listed herein, either in part or in whole will be given by the insurers to the holder of the certificate. Agent or Broker Comments: Signed by the Contractor: Date Signed (yyyy/mm/dd)
TO BE COMPLETED BY. X. Xxxxxxxx/Recruitment (pp. 1 – 3) Outreach worker or supervisor
TO BE COMPLETED BY. I. Outreach/Recruitment Outreach worker or supervisor
TO BE COMPLETED BY. YK#1 EMPLOYEE Employee's Family and Given Names (please print) Signature Relationship to Patient: Date: