Please Check One definition

Please Check One. Entire Hall:

Split View

AI-Powered Contracts

Draft, Review & Redline at the Speed of AI

Get StartedSchedule a Demo

Please Check One. Box: I am requesting a copy of my own record. I am requesting a copy of the record of another person, and I have attached their written consent. Other – for all other record requests, you must initial at least one permissible use in Part C of this Agreement, and you must check at least one of the following boxes: I am making a one-time request, and I will use the record one time and for one purpose. I am requesting on-line record access. (Skip Part B of this form if you are requesting record access). I am requesting Photo File access. (Skip Part B of this form if you are requesting Photo File access). Name of Requestor (Last) (First) (Middle Initial) Address Driver’s License or Non-Driver ID Number City State Zip Code Email Address Telephone Number ( ) - - Fax Number ( ) - - Requestor is an Authorized Representative of (List Name of Person or Entity): D- List dealer number if dealership Person/Entity Address City State Zip Code

Please Check One. ❑ New Member ❑ Renewal or Current Member Please Print (Head of Last Name Household) First Name Address Apt # City State Zip Telephone ( ) Date of Birth / / Email Address Last Name (If different from Head of Household) First Name Middle Initial Relationship to Head of Household Date of Birth Dependent Dependent Dependent Dependent Dependent Dependent Dependent I hereby apply for membership in the Colusa County Ground Ambulance Membership program for myself and eligible members who live at my address. I understand the enclosed fee provides emergency ambulance care and transportation within the Colusa County Ground Ambulance Service area, inter-facility transfers and non-emergency ambulance service as noted below. Coverage begins 3 days after acceptance of the application and extends one full calendar year from that date. Non-emergency ambulance service to hospitals and inter-facility transport from our local hospital to other approved facilities is covered when medically necessary. I understand that Colusa County Ground Ambulance Membership program is not insurance, but will provide ambulance service through the Colusa County Ambulance Service and will bill whatever insurance or medical benefits I may have. If a member is uninsured at the time of service, the member will be responsible to pay Colusa County Ground Ambulance $500.00. I further authorize the release of medical information for the purpose of ambulance insurance billing only. Should a family member or I receive payment from insurance or other medical benefits provider for ambulance service rendered by the Colusa County Ground Ambulance Service, I will immediately forward such payment to the Colusa County Ground Ambulance Service. Colusa County Ground Ambulance Membership program is not solicited from persons who receive Medi-Cal medical benefits and such membership constitutes a voluntary contribution only. I understand that violations of the terms of this agreement may result in immediate cancellation. This membership is non- refundable and non-transferable.

Examples of Please Check One in a sentence

• Please Check One: VISA MC DISC AMEX Expiration Date: / CVC: ZIP: Starting on / / 20 Ending on / / 20 This authorization is to remain in full force and effect until the ending date listed above.

• Term in Months 60 Please Check One: HP OEM No Supplies Included OWNER SIGNATURE TITLE DATED You acknowledge that the Equipment you have received may be equipped with a hard drive that may store personal and confidential information (“PCI”) and you understand the privacy and information security risks associated with PCI that may be stored on your Equipment.

• Please Check One ☐ Account is to be managed on a Discretionary Basis.

• Make Payable To Contact Person Contact‘s Phone Number Mailing Address City State ZIP Code Taxpayer ID # (SSN/FEIN or Payee) Tax Status (Please Check One): Corporation Tax Exempt Individual Other: Print Name Date Certifications and Signature I am authorizing the payment of the rebate to the third party named above and understand that I will not receive the rebate payment.

• Name on the Card: Please Check One: VISA MC DISC AMEX Expiration Date: / CVN: ZIP: Authorized Weekly Payment Amount: $ Week | % This authorization is to remain in full force and effect until the ending date listed above.

More Definitions of Please Check One

Please Check One. ▇▇▇-▇▇▇▇▇ Resident ($0.25/word) _ __ Non-Resident ($0.75/word)

Please Check One. All Inclusive HP OEM No Supplies Included OWNER SIGNATURE TITLE DATED

Please Check One. I want my child to check out a calculator from the THS Media Center. I understand that my child and I are personally responsible for the care of this calculator and will return it in working order at the end of the semester or be responsible for the fees listed above. I understand that my child CANNOT receive a diploma or replacement calculator until these fees are paid. I also understand that my child is responsible for having their calculator in class each day.

Please Check One. We are participating members of All Saints Catholic Parish (parish supported)

Please Check One. Band Member Guard Member Please Check One: Returning Member New Member Check Number Check Amount Parent/Guardian Phone_

Please Check One.  This is a new agreement  This is a modified agreement  Please terminate my current agreement I authorize my employer to defer the amount(s) above from my paycheck each pay period to be allocated to the

Please Check One. Entire Hall: 1st Floor Only: Wedding Package: