TO BE COMPLETED BY PROVIDER Sample Clauses

TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: BY: Authorized Signature NAME/TITLE: APPLICATION ID: If application was submitted online FEDERAL TAX I.D. NUMBER: TAX I.D. NAME: DATE: TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: Xxxxxx Xxxxxxxx, Program Administrator DATE: PROVIDER NUMBER: ************************************************************************************************************************ MAIL SIGNED AGREEMENT AND OTHER APPLICABLE DOCUMENTATION TO: DEPARTMENT OF SOCIAL SERVICES FINANCE/EBT 000 XXXXXXXXX XXXXX XXXXXX, XX 00000-0000
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TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: (Legal Name of Individual Provider for Individual Enrollments or Legal Name of Organization for Other Enrollment Types) BY: Authorized Signature (Must be Provider for Individual Enrollments) NAME: DATE: APPLICATION ID: (Printed Name of Signatory) (Complete only if new application submitted) SERVICING NPI: BILLING NPI: _ (Only applies if Agreement for individual enrollment type) BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ BILLING NPI: _ (Multiple Billing NPI fields are only acceptable when Agreement is for individual enrollment type) ENROLLMENT TYPE: FAOIP (Check one type, found on enrollment record) GROUP R. INDI S. INDI Tribal/IHS ************************************************************************************************************************ TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: REFERENCE NUMBER: DATE: NEW REVALIDATION RISK LEVEL
TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Addendum has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Addendum will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. Provider NPI: Provider Name: Legal Name of Individual Provider By: Name/Title: Authorized Signature of Provider Printed Name of Signatory Date: TO BE COMPLETED BY MEDICAL SERVICES Approved By: Reference Number: Date: New Revalidation

Related to TO BE COMPLETED BY PROVIDER

  • TO BE COMPLETED BY PARTICIPANT Date: Time: Broker Name: Firm Name: DTC Participant Number: Fax Number: Telephone Number: Type of Order (Check Creation or Redemption): Creation of FXB Redemption of FXB Number of Creation Units (CU) Transacted (One CU = 50,000 FXB): Number: Number Written Out: Order # This Order is subject to the terms and conditions of the Depositary Trust Agreement of the CurrencyShares® British Pound Sterling Trust as currently in effect and the Participant Agreement between the Authorized Participant, the Trustee and the Sponsor named therein. All representations and warranties of the Authorized Participant set forth in the Depositary Trust Agreement and such Participant Agreement are incorporated herein by reference and are true and accurate as of the date hereof. The undersigned does hereby certify as of the date set forth below that he/she is an Authorized Person under the Participant Agreement and that he/she is authorized to deliver this Order to the Trustee on behalf of the Authorized Participant. The Authorized Participant enters into this agreement based on an estimated Basket British Pound Amount disseminated the previous business day and recognizes the final Basket British Pound Amount represented will be increased or decreased based on the Trust’s daily accrual. At the conclusion of the trading day a Final NAV will be disseminated to all Authorized Participants, and the Basket British Pound Amount and Transaction Fee required for the creation/redemption order entered into on this day will be finalized and this Order will serve as a legally binding contract for settlement in 2 business days or as otherwise set forth in the Participant Agreement. Date Authorized Person’s Signature

  • TO BE COMPLETED BY TRUSTEE This certifies that the above order has been: Accepted by the Trustee Declined-Reason: Final # of Canadian Dollars Final # of FXC Shares Date Time Authorized Signature of Trustee ATTACHMENT A CREATION AND REDEMPTION OF CANADIAN DOLLAR SHARES AND RELATED CANADIAN DOLLARS TRANSACTIONS Scope of Procedures and Overview These procedures (the “Procedures”) describe the processes by which one or more Baskets of Canadian Dollar Trust shares (the “Shares”) issuable by The Bank of New York, as trustee (the “Trustee”) of the CurrencyShares Canadian Dollar Trust (the “Trust”), may be purchased or, once Shares have been issued, redeemed by an Authorized Participant. Shares may be created or redeemed only in blocks of 50,000 Shares (each such block, a “Basket”). Because the issuance and redemption of Baskets also involve the transfer of Canadian Dollars between the Authorized Participant and the Trust, certain processes relating to the underlying transfers of Canadian Dollars also are described. Under these Procedures, Baskets may be issued only in consideration for Canadian Dollars transferred to and held in the Trust’s accounts maintained in London, England by London Branch of JPMorgan Chase Bank, N.A., as depository (the “Depository”). Capitalized terms used in these Procedures without further definition have the meanings assigned to them in the Depositary Trust Agreement, dated as of June 8, 2006, between Rydex Specialized Products LLC (the “Sponsor”), the Trustee, the registered owners and beneficial owners from time to time of Shares issued thereunder and all depositors (the “Trust Agreement”), or the Participant Agreement entered into by each Authorized Participant with the Sponsor and the Trustee.

  • All Terms to be Conditions The Company agrees that the conditions contained in this Agreement will be complied with insofar as the same relate to acts to be performed or caused to be performed by the Company. Any breach or failure to comply with any of the conditions set out in this Agreement shall entitle any of the Underwriters to terminate their obligation to purchase the Offered Shares, by written notice to that effect given to the Company at or prior to the Closing Time or the Option Closing Time, as applicable. It is understood that the Underwriters may waive, in whole or in part, or extend the time for compliance with, any of such terms and conditions without prejudice to the rights of the Underwriters in respect of any such terms and conditions or any other or subsequent breach or non-compliance, provided that to be binding on any Underwriter any such waiver or extension must be in writing and signed by such Underwriter.

  • Waiver of Right to Trial by Jury EACH PARTY TO THIS AGREEMENT HEREBY EXPRESSLY WAIVES ANY RIGHT TO TRIAL BY JURY OF ANY CLAIM, DEMAND, ACTION OR CAUSE OF ACTION ARISING UNDER ANY LOAN DOCUMENT OR IN ANY WAY CONNECTED WITH OR RELATED OR INCIDENTAL TO THE DEALINGS OF THE PARTIES HERETO OR ANY OF THEM WITH RESPECT TO ANY LOAN DOCUMENT, OR THE TRANSACTIONS RELATED THERETO, IN EACH CASE WHETHER NOW EXISTING OR HEREAFTER ARISING, AND WHETHER FOUNDED IN CONTRACT OR TORT OR OTHERWISE; AND EACH PARTY HEREBY AGREES AND CONSENTS THAT ANY SUCH CLAIM, DEMAND, ACTION OR CAUSE OF ACTION SHALL BE DECIDED BY COURT TRIAL WITHOUT A JURY, AND THAT ANY PARTY TO THIS AGREEMENT MAY FILE AN ORIGINAL COUNTERPART OR A COPY OF THIS SECTION WITH ANY COURT AS WRITTEN EVIDENCE OF THE CONSENT OF THE SIGNATORIES HERETO TO THE WAIVER OF THEIR RIGHT TO TRIAL BY JURY.

  • Right to Work For purposes of federal immigration law, you will be required to provide to the Company documentary evidence of your identity and eligibility for employment in the United States. Such documentation must be provided to us within three (3) business days of your Start Date, or our employment relationship with you may be terminated.

  • Right to Join Employees shall have the right to form and join labor or employee organizations, and shall have the right not to form and join such organizations. Employees in an appropriate unit shall have the right by secret ballot to designate an exclusive representative for the purpose of negotiating grievance procedures and the terms and conditions of employment for employees of such unit with the School Board.

  • EXCEPTIONS OR REVISIONS WILL BE CONSIDERED DIR shall have the absolute right to terminate the Contract without recourse in the event that:

  • Compliance with Contractor Employee Jury Service Ordinance Contractor shall comply with the County Ordinance with respect to provision of jury duty pay to employees and have and adhere to a written policy that provides that its employees shall receive from the Contractor, on an annual basis, no less than five days of regular pay for actual jury service in San Mateo County. The policy may provide that employees deposit any fees received for such jury service with the Contractor or that the Contractor deduct from the employees’ regular pay the fees received for jury service.

  • Right to Review After receiving written notice of the denial of a claim, a claimant or his representative shall be entitled to:

  • Representations Relating to Documents and Legal Compliance Borrower represents and warrants to Silicon as follows: All statements made and all unpaid balances appearing in all invoices, instruments and other documents evidencing the Accounts are and shall be true and correct and all such invoices, instruments and other documents and all of Borrower’s books and records are and shall be genuine and in all respects what they purport to be. All sales and other transactions underlying or giving rise to each Account shall comply in all material respects with all applicable laws and governmental rules and regulations. To the best of Borrower’s knowledge, all signatures and endorsements on all documents, instruments, and agreements relating to all Accounts are and shall be genuine, and all such documents, instruments and agreements are and shall be legally enforceable in accordance with their terms.

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