Witness Signature 4. PARENT/GUARDIAN CONSENT: (for applicants under 18 years) – I hereby certify and decree that all the information contained in the declarations above is true and accurate Print Name:................................................................... Signature …………………………………………....……... Relationship to applicant ……………………………… Phone Contact ……………………................................... Address …………………………………………………………………….....................................................................
Counterpart Signature This Agreement may be signed in counterpart, and the signed copies will, when attached, constitute an original Agreement.
Signature Signature For Messrs. Ehsan Auctioneers Sdn Bhd For Messrs. Zulpadli & Xxxxx Xxxx’ Haji Xxxxx Xxxxx X.X. Xxxx (D.I.M.P) SOLICITOR FOR THE ASSIGNEE LICENSED AUCTIONEERS ONLINE TERMS AND CONDITIONS The Terms and Conditions specified herein shall govern all members of xxx.xxxxxxxxxxxxxxxx.xxx (“EHSAN AUCTIONEERS SDN. BHD. website”).
Required Signatures a. Curriculum Academic Xxxx(s) b. Curriculum Chair(s)
Counterpart Signatures For the purpose of facilitating the recordation of this Agreement as herein provided and for other purposes, this Agreement may be executed simultaneously in any number of counterparts, each of which counterparts shall be deemed to be an original, and such counterparts shall constitute but one and the same instrument.
AGREEMENT SIGNATURES By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signєd by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signєd by ™єprєsєnĒaĒivє: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Name of Representative: Signature of Representative: Date: SignaĒurє on bєhalf of FighĒing Chancє: Name of Representative: Xxxx Xxxxx Signature of Representative: Date: 28.11.2023 Appendix 1 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. Please note, funding for Positive Behavior Support is billed from the Capacity Building Relationships category, which is often NDIA Managed. Please advise if your CB relationship funding is managed di erently. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx A statement of account is available on request directly from your clinician. ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services to the email below. Please email invoices to: Please see Appendix 3 for Self-Management Payment Options. ☐ PLAN-MANAGED Please send invoices to my plan manager: Plan management organisation Contact Name Email Address Phone number ☐ OTHER FUNDING (eg. self-funded) Please email invoices to: Appendix 2 Self-Managed Payment Options Participants who are self-managed have a number of payment options with Fighting Chance: ☐ DIRECT DEPOSIT (preferred option) Payment of Fighting Chance invoices can be made by Electronic Funds Transfer (EFT) through your bank. Fighting Chance’s bank account details are as follows: Bank: Commonwealth Bank of Australia Account Name: Fighting Chance Australia Ltd BSB: 062-438 Account Number: 00000000 To ensure all payments are correctly allocated to your account, please include the full invoice number in the reference field. ☐ CREDIT CARD Payments can be made by credit card by clicking the ‘pay by credit card’ link included on the invoice. Please note that a service fee for this option will be imposed. ☐ PAYPAL Payment of your invoices can also be made via our PayPal account. To make payment via PayPal, please access the following link: xxxxx://xxxxxx.xx/FightingChanceAus?locale.x=en_AU
