Electronic Signature AgreementElectronic Signature Agreement • December 10th, 2008
$ I agree to maintain the security of the UserID and Password assigned to me by U.S. EPA for use of the CAMD Business System, in order to prevent disclosure of this information to anyone.
Santa Barbara County Department of Behavioral Wellness Electronic Signature AgreementElectronic Signature Agreement • January 17th, 2019
Electronic Signature AgreementElectronic Signature Agreement • December 10th, 2008
$ I agree to maintain the security of the UserID and Password assigned to me by U.S. EPA for use of the CAMD Business System, in order to prevent disclosure of this information to anyone.
Submit Initial Electronic Signature Agreement forms to: Mental Health Plan: BWellQCM@sbcbwell.orgElectronic Signature Agreement • October 8th, 2020
MISSION FEDERAL CREDIT UNION AGREEMENTS AND DISCLOSURESElectronic Signature Agreement • July 17th, 2020
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • August 3rd, 2022
This Agreement governs the rights, duties, and responsibilities of San Bernardino County Department of Behavioral Health (DBH) in the use of an electronic signature in San Bernardino County. The undersigned understands that this Agreement describes the obligations to protect his/her electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed. I agree to the following terms and conditions:
Electronic Signature Agreement (ESA) for EPA’s Verify System To be signed and submitted by a Company Approving OfficialElectronic Signature Agreement • December 10th, 2020
Agree to protect the electronic signature credential, consisting of my Central Data Exchange (CDX) user identification and password, from use by anyone except me. Specifically, I agree to maintain the secrecy of the password; I will not divulge or delegate my user name and password to any other individual; I will not store my password in an unprotected location; and I will not allow my password to be written into computer scripts to achieve automated login.
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • November 26th, 2019
This Agreement governs the rights, duties, and responsibilities of San Bernardino County Department of Behavioral Health (DBH) in the use of an electronic signature in San Bernardino County. The undersigned understands that this Agreement describes the obligations to protect his/her electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed. I agree to the following terms and conditions:
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • August 23rd, 2020
The undersigned Individual and Employing Entity attest that they have entered into an agreement effective on the date indicated below. Both parties agree an authorized representative of the Employing Entity has the authority to sign and submit the electronic Michigan Department of Health and Human Services Medical Assistance Provider Enrollment Trading Partner Agreement and to maintain enrollment information through the MDHHS CHAMPS Provider Enrollment Subsystem. Both parties also agree that the Employing Entity listed above is liable and bound by all information submitted on his or her behalf as if the Employing Entity had submitted changes to CHAMPS directly.
Electronic Signature AgreementElectronic Signature Agreement • August 2nd, 2020
High Plains Regional Education Cooperative permits related service providers (i.e., therapists) to electronically authenticate service entries in TIENET/Service Capture.
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • August 4th, 2014
The undersigned understands that this Agreement describes my obligations to protect my electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed. I agree to the following terms and conditions:
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • July 30th, 2012
This notice describes our Electronic Signature Agreement, how your Electronic Signature may be obtained and used, and your rights in regard to this information. Please review it carefully. If you have any questions about this notice, please contact our office at (919) 563-0000, info@matteochiropractic.com, or Matteo Chiropractic, PLLC, 941 S Fifth Street, Mebane, NC 27302.
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • November 19th, 2019
This Agreement governs the rights, duties, and responsibilities of Department of Mental Health in the use of an electronic signature in County of Los Angeles. In addition, I, the undersigned, understand that this Agreement describes my obligations to protect my electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed.
ELECTRONIC SIGNATURE AGREEMENT for Michigan Air Emissions Reporting System (MAERS)Electronic Signature Agreement • September 21st, 2020
In order to become the Primary Preparer and receive a Personal Identification Number (PIN) for submittal of your emission inventory report, you must print this form, sign it, and return it to the Michigan Department of Environment, Great Lakes, and Energy (EGLE). Once the form is received, EGLE personnel will review your application and approve your Primary Preparer account as appropriate.
Electronic Signature AgreementElectronic Signature Agreement • January 30th, 2017
The undersigned Individual and Employing Entity attest that they have entered into an agreement effective on the date indicated below. Both parties agree an authorized representative of the Employing Entity has the authority to sign and submit the electronic Illinois Department of Healthcare and Family Services Medical Assistance Provider Enrollment Trading Partner Agreement and to maintain enrollment information through the H FS IMPACT Provider Enrollment Subsystem. Email completed form to Impact.Help@Illinois.Gov
STATEMENT OF AGREEMENT TO PROCESS NEEDED SIGNATURES OF THE VIRGINIA DEPARTMENT OF HEALTH (VDH) LOCAL GOVERNMENT AGREEMENT ELECTRONICALLYElectronic Signature Agreement • April 20th, 2022
Electronic Signature AgreementElectronic Signature Agreement • January 30th, 2017
The undersigned Individual and Employing Entity attest that they have entered into an agreement effective on the date indicated below. Both parties agree an authorized representative of the Employing Entity has the authority to sign and submit the electronic Illinois Department of Healthcare and Family Services Medical Assistance Provider Enrollment Trading Partner Agreement and to maintain enrollment information through the H FS IMPACT Provider Enrollment Subsystem.
Important Electronic Signature Agreement (ESA) DetailsElectronic Signature Agreement • January 9th, 2019
When you submit your ESA via RCRAinfo, the system evaluates and scores the information you submit to prove your identity. Depending on your score, the system will either:
ContractElectronic Signature Agreement • December 13th, 2018
PROVIDER ELECTRONIC SIGNATURE AGREEMENT COVER SHEET Michigan Department of Health and Human Services Instructions • Provider should retain a COPY in the office • MUST be submitted with DCH-1401, Electronic Signature Agreement. Mail to: Email to: Michigan Department of Health and Human Services ProviderEnrollment@michigan.gov Provider Enrollment Section PO Box 30238 Lansing, MI 48909 Fax: 517-241-8233 Reason for Submission (check all that apply) Revalidation New Tax ID/SSN (List Provider Enrollment staff contact name) Domain Access Other (List reason) Group Individual Both Domain Administrator Contact Information Contact Information (REQUIRED) Name Email Address Phone Number MILogin User ID Provider’s NPI Number Provider’s Date of Birth Provider’s Home Address Provider Enrollment Office Use Only Provided Domain Administrator contact information Sent/Gave to team lead for processing Sent to processor with W-9 attached Opened for
Electronic Signature AgreementElectronic Signature Agreement • September 14th, 2020
• I agree to maintain the security of the User ID and Password assigned to me by U.S. EPA for use of the CAMD Business System, in order to prevent disclosure of this information to anyone.
Electronic Signature AgreementElectronic Signature Agreement • May 26th, 2020
This Agreement will allow you to electronically submit forms and reports using the DEQ ePortal and SLEIS systems when those forms and reports require a signature, using the account identified by your email address. To receive the necessary authorization, you must fill out this form completely, sign it, and send the original to:
CONSENT AND NOTICE REGARDING ELECTRONIC COMMUNICATIONSElectronic Signature Agreement • August 2nd, 2020
The following disclosures are required by the federal Electronic Signatures in Global and National Commerce Act (“ESIGN”). They are necessary to make requests regarding your accounts and loans electronically.
MARIN WITS ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • July 8th, 2015
This Agreement governs the rights, duties, and responsibilities of County of Marin- Health & Human Services staff and contract providers in the use of an electronic signature in Marin WITS. A Marin Wits is comprised of user’s unique user name, password and pin. The undersigned (I) understands that this Agreement describes my obligations to protect my electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed. I agree to the following terms and conditions:
Electronic Signature AgreementElectronic Signature Agreement • October 19th, 2017
As a convenience, Lakeway Christian Schools (LCS) will utilize electronic forms to obtain important information from our families. Under this method, parents and/or legal guardians will have the option to sign certain documents electronically. The documents executed electronically will be treated like a physical handwritten signature on a paper form. The law requires that we provide certain information to you and obtain your consent to use an electronic signa- ture. Please carefully read the following information.
Electronic Disclosure and Electronic Signature AgreementElectronic Signature Agreement • September 16th, 2022
The Electronic Signatures in Global and National Commerce Act (ESIGN) requires your approval before we can provide services to you electronically. Please read this Electronic Records Disclosure and Agreement carefully and save or print a copy for your records.
Electronic Signature Agreement MoFirstSteps.comElectronic Signature Agreement • June 2nd, 2004
This is to certify my request for an electronic signature. An electronic signature is similar to your handwritten signature. Through the use of an electronic signature, you agree that the information you provide is accurate and complete to the best of your knowledge. You also acknowledge that you have read and understand the following statements. Please read these notices before providing us with your request for your electronic signature:
Electronic Signature AgreementElectronic Signature Agreement • May 7th, 2022
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • January 25th, 2011
In accepting the electronic signature credential issued by the U.S. Environmental Protection Agency (EPA) to sign electronic documents submitted to EPA's Central Data Exchange (CDX), and as a representative for:
Electronic Signature AgreementElectronic Signature Agreement • December 12th, 2019
This agreement governs the rights, duties and responsibilities of Enki Health and Research Systems, Inc. in the use of an electronic signature in Los Angeles County. The undersigned (I) understands that this Agreement describes my obligations to protect my electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed. I agree to the following terms and conditions:
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • July 20th, 2022
This Electronic Signature Agreement (“Agreement”) shall control for matters or services related to the subject matter of this Agreement. As part of these transactions, you may use our E-Services site. Your use of the E-Services site will be governed by the E-Services Terms and Conditions of Use.
Electronic Signature Agreement (ESA) for theElectronic Signature Agreement • May 29th, 2020
This Agreement will allow you to electronically submit the electronic Used Tire Manifest using the DEQ ePortal manifest system. Your account identification is your email address. To receive the necessary authorization, you must fill out this form completely, sign it, and submit the original to:
MISSION FEDERAL CREDIT UNION AGREEMENTS AND DISCLOSURESElectronic Signature Agreement • February 11th, 2022
The terms and conditions of this Agreement apply to the electronic delivery of Mission Federal Credit Union’s account statements, periodic statements, notices, and disclosures in connection with each account that you have with us.
Santa Barbara County Department of Behavioral Wellness Electronic Signature AgreementElectronic Signature Agreement • June 26th, 2018
ELECTRONIC SIGNATURE AGREEMENTElectronic Signature Agreement • September 13th, 2017
This Agreement governs the rights, duties, and responsibilities of Department of Mental Health in the use of an electronic signature in County of Los Angeles. In addition, I, the undersigned, understand that this Agreement describes my obligations to protect my electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed.
Electronic Signature AgreementElectronic Signature Agreement • October 11th, 2002
By checking the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By checking "I Accept" you consent to be legally bound by this Agreement's terms and conditions.
