Acknowledgement of Disclosure. By continuing with this registration, I confirm that my consents and approvals set forth above are freely given, specific, informed, and unambiguous.
Acknowledgement of Disclosure. OF CREDIT INFORMATION TO A CREDIT REPORTING BODY 10 23. AGREEMENT/AUTHORITY FOR CREDIT PROVIDER TO PERFORM CERTAIN PERMITTED ACTIONS CONCERNING A FINANCE APPLICATION OR TRANSACTION 10 24. ACKNOWLEDGEMENT OF DISCLOSURE OF THE CREDIT PROVIDER’S COLLECTION AND HANDLING OF CREDIT INFORMATION AND CREDIT ELIGIBILITY INFORMATION (INFORMATION SUPPLIED BY A CREDIT REPORTING BODY) 11 The purpose of this document is to give you information you may require to make an informed decision about whether to subscribe to use Crystella Pty Ltd (Crystella) product(s) and to set out the terms and conditions of any such subscription. This document contains your rights and obligations when subscribing to a Crystella subscription. Please read them carefully. You agree that your subscription for and use of the Crystella product(s) constitutes your acceptance of these terms, which may later be amended from time to time. This Agreement as amended from time to time applies to your use of any Crystella product. All future changes set out in a notice or update from Crystella are incorporated by reference into this Agreement and the changes will take effect on the date specified in the notice or update. The information in this Agreement is current as at the date this Agreement is ”Accepted”. Crystella may change some of the terms of the Agreement if they are not materially adverse to you from time to time without needing to notify you under the terms of Clause 18 of this Agreement. You may review that changed information and the current version of this Agreement at any time by visiting our website. If you wish to review previous versions of this Agreement, please click here to send us a request for copies.
Acknowledgement of Disclosure. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Signature of Individual who is 18 years or older / or Parent/Legal Guardian on behalf of Individual who is not 18 years or older Printed Name of Individual Printed Name of Parent/Legal Guardian and Relationship to Individual Date APPENDIX B 4819-6011-3661v.1 0118030-000001 XXXXXXXX X ASSIGNMENT OF BENEFITS FOR COVID-19 TESTING I, the undersigned, irrevocably assign to Covid Clinic, Inc. (“Covid Clinic”) and/or MedLab2020 (“MedLab”), all of my rights and benefits and any other interests that I have in my medical insurance plan, health benefit plan, indemnity plan, trust, fund or other source of payment for healthcare services identified below (each a “Plan”) in connection with the COVID-19 Testing provided by Covid Clinic, MedLab, and their employees or agents. I understand that this document is a direct assignment of my rights and benefits under my Plan. I instruct my insurance company to pay Provider directly for the professional or medical expense benefits payable to me. In addition, I agree and understand that any funds I receive from my insurance company due for services rendered by Covid Clinic and/or MedLab will be immediately signed over and sent directly to Covid Clinic and/or MedLab. I authorize Covid Clinic and/or MedLab and their agents to release any medical or other information about me in its possession to my Plan, the Social Security Administration, the Centers for Medicare and Medicaid Services, any state administrative agency, or their intermediaries or fiscal agents required or requested in connection with any claim for services rendered to me by Covid Clinic and/or MedLab. Plan Name: Policy Holder’s Name: Relationship to Policy Holder: ID Number: Group Number: Signature of Individual who is 18 years or older Printed Name of Individual Printed Name of Parent/Legal Guardian and Relationship to Individual Date APPENDIX B
Acknowledgement of Disclosure. The Trust and the Adviser hereby acknowledge receipt of Part II of the Sub-Adviser’s Form ADV as required pursuant to Rule 204-3 under the Advisers Act prior to the date of this Agreement.
Acknowledgement of Disclosure. Client hereby acknowledges receipt of Advisor’s Disclosure Statement as required pursuant to Rule 204-3 (17 CFR 275.204-3) under the Investment Advisor’s Act of 1940 prior to or on the date (shown below) of the Client’s signing of this agreement. Termination by Client. Client shall have the option to terminate this Agreement in its entirety exercisable at Client’s sole option, and without penalty, for five days from the date (shown below) of the Client’s signing of this Agreement; provided, however, that any investment action taken by the Advisor with respect to the Account during such five day period in reliance upon this Agreement and prior to receipt of actual notice of the Client’s exercise of this right of termination, shall be at the sole risk of the Client.
Acknowledgement of Disclosure. PPF has disclosed to the CME Parties a possible Claim as described in section 4.9 of the Disclosure Letter, and the CME Parties acknowledge that such disclosure has been made, and further acknowledge that the filing of such a Claim (based on the facts and theories disclosed) after the Execution Date shall not constitute a breach of any Warranty made by PPF.
Acknowledgement of Disclosure. Purchaser acknowledges that it has been made available for his review all public filings with the SEC and any other documentation and materials that he has reasonably requested. Purchaser has reviewed the attached SEC Form 10-KSB, dated 12/31/06 and SEC Form 10-QSB, dated 9/30/07.
Acknowledgement of Disclosure. Client acknowledges receipt of the below initialed documents on , 20 . Initial(s) Below Form ADV Part 2A (for Adviser, Madison Avenue Securities, LLC) Form ADV Part 2B Brochure Supplement for IAR Form CRS (Customer Relationship Summary) Master Relationship Disclosure (Including Privacy Policy, Terms and Conditions, and other important disclosures)
