APPLICANT AGREEMENT. I understand that if any assistance is needed in setting up equipment or involves computer-related equipment, I will make arrangements with the Adult Services Department at least 48 hours prior to the meeting time. I understand that I will be responsible for and must make good any damage to the library's equipment while it is in my use. I further understand that use of video-projection equip- ment must cease at least 30 minutes before the library closes to allow for shutdown procedures. Signature of person completing this application form Date Please notify the Adult Services Department of any problems with equipment. FOR STAFF USE Date rec'd Time rec'd Rec'd by Date group notified Branch Manager Approved Y N Date approved Calendar Entry
APPLICANT AGREEMENT. The agent has explained the details of the coverage(s)/benefits and I, the undersigned, acknowledge reading the entire application, including the Claims Funding Agreement and Administrative Services Agreement. The answers I have provided are true and complete. I understand that the terms and conditions herein binds the applicant only when the applicant receives written approval. Full Legal Business Name Signature Name Dated on / /
APPLICANT AGREEMENT. The agent has explained the details of the coverage(s)/benefits and I, the undersigned, acknowledge reading the entire application, including the Claims Funding Agreement and Administrative Services Agreement. The answers I have provided are true and complete. I understand that the terms and conditions herein binds the applicant only when the applicant receives written approval. The Secure Plans are level-funded plans designed to set your company's maximum financial responsibility. however, you may be subject to financial responsibility greater than your final quoted rates under some circumstances. For example, errors by the administrator or by you may result in additional financial exposure. To minimize such exposure, the administrator and employer must manage this plan in accordance with the standard plan documents. The excess-loss carrier has the right to audit claim and eligibility information prior to funding claims filed under the stop-loss policy. Full Legal Business Name: Signature: Name: Dated on / /
APPLICANT AGREEMENT. I understand that if any assistance is needed in setting up equipment or involves computer-related equipment, I will make arrangements with the AV Department at least 48 hours prior to the meet- ing time. I understand that I will be responsible for and must make good any damage to the library's equipment while it is in my use. I further understand that use of video-projection equipment must cease at least 30 minutes before the library closes to allow for shutdown procedures. Signature of person completing this application form Date Please notify the Audiovisual Department of any problems with equipment. FOR STAFF USE Date rec'd Time rec'd Rec'd by Date group notified Branch Manager Approved Y N Date approved
APPLICANT AGREEMENT. The applicant agrees to abide by the following requirements by initialing each requirement. There are limited exceptions to these requirements. Applicant Initials Applicant Agrees to the Following Requirements
APPLICANT AGREEMENT. The agent has explained the details of the coverage(s)/benefits and I, the undersigned, acknowledge reading the entire application, including the Claims Funding Agreement and Administrative Services Agreement. The answers I have provided are true and complete. I understand that the terms and conditions herein binds the applicant only when the applicant receives written approval. The Secure Plans are level-funded plans designed to set your company's maximum financial responsibility. however, you may be subject to financial responsibility greater than your final quoted rates under some circumstances. For example, errors by the administrator or by you may result in additional financial exposure. To minimize such exposure, the administrator and employer must manage this plan in accordance with the standard plan documents. The excess-loss carrier has the right to audit claim and eligibility information prior to funding claims filed under the stop-loss policy. Full Legal Business Name: Signature: Name: Dated on / / Benefits are not effective until you receive written approval from the program underwriter or administrator. Do not cancel coverage until you receive written notice of approval. Applications will not be underwritten until all required information is submitted. The deposit amount will be returned to you if the Application is denied.
APPLICANT AGREEMENT. The applicant agrees that during the instruction periods, they will refrain from conducting activities associated with their current position, including but not limited to conference calls and work deliverables. Additionally, the applicant agrees that missed instruction days and lab work shall be completed on their own time so the applicant does not fall behind the others in their cohort. Lastly, if applicant while in class fails to complete the required work assigned in the duration allotted, they agree to complete such work during their personal hours.
APPLICANT AGREEMENT. I, the undersigned, hereby agree that the information provided is complete, accurate, and will be maintained in the West Virginia State Training and Registry System. I understand that I am responsible for this information and agree to update my profile when applicable. I understand that West Virginia State Training and Registry System is a public entity and will protect the confidentiality of personal information provided to the extent permitted under state and federal law. Registry information may be accessed by relevant outside parties (i.e. regulatory agencies, employers, program administrators). I understand that the information provided to West Virginia State Training and Registry System will be used for the following purposes: -Recognize individuals' educational attainments -Aid community and state planning to increase the quality and services of the early care and education community -Integrate with additional workforce and professional development agencies -Compile and publish individual and group data reports *Profile data will be submitted to The National Workforce Registry Alliance to create an accurate and current national data set of early childhood workforce data. Your name will not be released to advertisers. Information that could affect the safety and security of an individual (i.e. personal addresses) will not be released to any individual or agency for any reason. Signature Date
APPLICANT AGREEMENT. 4.1 agrees that the information in this document is Organization Name true and accurate.
APPLICANT AGREEMENT. In signing this application, I understand and agree to complete volunteer orientation and animal handling training before interacting with animals. Signature: Date: RELEASE OF LIABILITY: As a volunteer for FACILITY/COUNTY, I acknowledge that I am subject to risks of personal injury, including property damage. In consideration for being allowed to volunteer for FACILITY/COUNTY, whether on or off the premises of FACILITY/COUNTY, on behalf of myself, my executors, administrators, heirs of kin, successors and assignees, I hereby, release, discharge and agree to hold harmless FACILITY/COUNTY, its staff from any and all claims and liability for any injury, disability or damage I may incur whether to my person or my property as a result of my volunteer activities. Printed Name: Signature: Madison County Animal Care and Control Staff:
