PLEASE COMPLETE AND EMAIL TO:Please Complete And • January 31st, 2019
AGREEMENT A DETAILS OF BUILDING Description (Mark in relevant block) Business Residential Name of building Unit No COMMENCEMENT DATE FOR ELECTRICITY SUPPLY dd / mm / yyyy Mark the relevant block Tenant Owner Deposit Payable in advance B DETAILS OF PERSON/LEGAL ENTITY LIABLE FOR PAYMENT OF SERVICES Name of Company/Close Corporation/Trust/Private Person Registration number / identity number Physical/Registered Address Telephone No (Home) Cell No Work No VAT NUMBER C TAX INVOICE MUST BE DELIVERED VIA: E-mailed: Email Address: Hand Delivered: D EMPLOYER’S DETAILS (IN THE EVENT OF A PRIVATE PERSON) Name of Company Address Postal code Telephone No Fax No E DETAILS OF SPOUSE (IN THE EVENT OF A PRIVATE PERSON) Full Names Surname Identity No Telephone No Fax No Employer F REFERENCES OF 1 PERSON NOT LIVING WITH YOU OR IN THE EVENT OF A BUSINESS A REFERENCE FROM ONE OF YOUR CREDITORS Name Address Postal Code Telephone No
North CaroliNa CoaChes assoCiatioNPlease Complete And • February 1st, 2013
PLEASE COMPLETE AND EMAIL TO:Please Complete And • November 7th, 2022
AGREEMENT A DETAILS OF BUILDING Description (Mark in relevant block) Business Residential Name of building Unit No COMMENCEMENT DATE FOR ELECTRICITY SUPPLY dd / mm / yyyy Mark the relevant block Tenant Owner Deposit Payable in advance B DETAILS OF PERSON/LEGAL ENTITY LIABLE FOR PAYMENT OF SERVICES Name of Company/Close Corporation/Trust/Private Person Registration number / identity number Physical/Registered Address Telephone No (Home) Cell No Work No VAT NUMBER C TAX INVOICE MUST BE DELIVERED VIA: E-mailed: Email Address: Hand Delivered: D EMPLOYER’S DETAILS (IN THE EVENT OF A PRIVATE PERSON) Name of Company Address Postal code Telephone No Fax No E DETAILS OF SPOUSE (IN THE EVENT OF A PRIVATE PERSON) Full Names Surname Identity No Telephone No Fax No Employer F REFERENCES OF 1 PERSON NOT LIVING WITH YOU OR IN THE EVENT OF A BUSINESS A REFERENCE FROM ONE OF YOUR CREDITORS Name Address Postal Code Telephone No
PLEASE COMPLETE AND RETURN THE LAST PAGE TO DR. PADDOCKPlease Complete And • September 23rd, 2021
Welcome to my practice. This Agreement contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your
PLEASE COMPLETE AND RETURN THE LAST PAGE TO DR. PADDOCKPlease Complete And • July 13th, 2020
This Agreement contains important information about me, my professional services, and my business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. You may revoke this Agreement in writing at any time.
PLEASE COMPLETE AND RETURN THE LAST PAGE TO DR. PADDOCKPlease Complete And • June 18th, 2021
This Agreement contains important information about me, my professional services, and my business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. You may revoke this Agreement in writing at any time.
HOLD HARMLESS AGREEMENTPlease Complete And • June 27th, 2019
IN CONSIDERATION of the use of school buildings, grounds, facilities and equipment of Independent School District No. 832 on the day of , 20 ,
PLEASE COMPLETE AND FORWARD TO EKSDAY@SPECIALOLYMPICS.ORG. LICENSE AGREEMENTPlease Complete And • August 16th, 2010 • District of Columbia
Licensee shall not reproduce, distribute or sub-license the Mark, except for the use in connection with the Permitted Usage of the Mark described herein.
Welsh Art Auction 2008 Washington Gallery Contract of SalePlease Complete And • October 9th, 2008
PLEASE COMPLETE AND RETURNPlease Complete And • May 24th, 2016
PLEASE COMPLETE AND EMAIL TO:Please Complete And • November 25th, 2016
AGREEMENT A DETAILS OF BUILDING Description (Mark in relevant block) Business Residential Name of building Unit No COMMENCEMENT DATE FOR ELECTRICITY SUPPLY dd / mm / yyyy Mark the relevant block Tenant Owner Deposit Payable in advance B DETAILS OF PERSON/LEGAL ENTITY LIABLE FOR PAYMENT OF SERVICES Name of Company/Close Corporation/Trust/Private Person Registration number / identity number Physical/Registered Address Telephone No (Home) Cell No Work No VAT NUMBER C TAX INVOICE MUST BE DELIVERED VIA: E-mailed: Email Address: Hand Delivered: D EMPLOYER’S DETAILS (IN THE EVENT OF A PRIVATE PERSON) Name of Company Address Postal code Telephone No Fax No E DETAILS OF SPOUSE (IN THE EVENT OF A PRIVATE PERSON) Full Names Surname Identity No Telephone No Fax No Employer F REFERENCES OF 1 PERSON NOT LIVING WITH YOU OR IN THE EVENT OF A BUSINESS AREFERENCE FROM ONE OF YOUR CREDITORS Name Address Postal Code Telephone No
Please complete and sign the Electronic Commerce User Agreement ("Agreement") below, and fax, mail or email it to KW Automotive at the address below. KW Automotive will process your request and provide you with an email notification of your login and...Please Complete And • January 10th, 2017
Read all terms and conditions of this agreement before signing or accessing the KW Automotive B2B Website or any KW Automotive database. By accessing the Web Site or informational database, your organization ("Customer") agrees to these terms and conditions, as modified or amended. Each time you access the database or site, you reconfirm your agreement. If you do not agree to these terms and conditions, you may elect not to access the database or site. This Agreement is effective from the day you initially access the database or site until such time as you terminate the Agreement.
PLEASE COMPLETE AND SIGN ALL THE FOLLOWING FORMS AND BRING TO NEXT EVENT ORPlease Complete And • November 2nd, 2021
Your participation in Jefferson Boys Lacrosse Booster Club Sponsored events, and allowance of your son to participate, along with your signature below, demonstrates each of your acceptances of the following rules/procedures:
PRE- AUTHORIZED PAYMENT SERVICE AGREEMENTPlease Complete And • September 30th, 2015
The undersigned hereby authorizes Associa British Columbia, Inc. to draw monthly debits by paper or electronic entry covering payments due by the undersigned to:
