TO BE COMPLETED BY. Parent (s) / Guardian(s) Marital Status of Parent (s)/ Guardian (s):Married Separated/Divorced Single/Widowed Common-LawIf the applicant's parents are separated/divorced, please provide the information and signature (on page 3) for the parent/stepparent who has custody of the applicant. If neither parent has custody, please provide the information and signature for the parent./stepparent with whom the applicant resides.Occupation and yearly income of parents:Father/Stepfather/Guardian Mother/Stepmother/GuardianOccupationYearly gross income $ Page 2 of 3 List names, ages, and relationship of individuals who are dependent on you, including applicant Name:Age:Name:Age:Name:Age:Name:Age:How many of the dependents listed above will be attending a post-secondary institution on a full time basis during the upcoming academic year?
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. 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 If you want to elect to have this Security purchased by the Company pursuant to Sections 4.16 or 4.17 of the Indenture, check the appropriate box:
TO BE COMPLETED BY. EMPLOYER The Guarantor, , is employed with . The Guarantor is eligible for payroll deduction. The Guarantor’s payroll will be deducted in the amount of $ every (insert timing of payroll time period). The total amount of deduction will be , beginning on pay period beginning and ending on . Name and Title of Authorized Representative Signature Date 4 TO BE COMPLETED BY GUARANTOR/EMPLOYEE I, , the Guarantor, work for . I am paid every . I agree to pay GMHA, through payroll deduction, $ every . I understand that I am agreeing to deduct this payment from my wages or salary beginning on , in payroll periods – or until the amount due is paid in full. Guarantor’s (Employee’s) Signature Date 5 TERMS OF THIS AGREEMENT – By completing and submitting this agreement, the Guarantor/Employee agrees: You will make each payment so that we receive it at the time specified in Boxes 4 and 5. If a scheduled payment will not be made, contact GMHA immediately. This Agreement is based on your current financial condition. We may modify or terminate the agreement if our information shows that your ability to pay has significantly changed. You must provide updated financial information when requested. If you default on your PR Deduction Agreement, or withhold information that may change or affect this agreement, GMHA may terminate this Agreement, pursue collection or utilize legal services to seek full payment of the balance due. We can terminate your PR Deduction Agreement if you do not make installment payments as agreed, or you do not provide financial information when requested. If we terminate your agreement, we may collect the entire amount you owe through legal proceedings, collections, or debt recovery service. This agreement may require managerial approval. We will notify you when we approve or do not approve the agreement.