Check Number. This may be located between the routing number and the account number or after. (Do not include) If you have any questions, please contact us at: XXX.Xxxxxxxxxxx@xxxxxx.xxx or (000) 000-0000 Routing Number Check Number xxxx://xxx.xxxxxx.xxx/DAS/Financial/AcctgSys/Pages/ach.aspx Retain a copy for your records Appendix 7 Coordinated Care Model Provisions
Check Number. May appear before the Routing Number or after the Account Number. Ç ATTACH CANCELED CHECK HERE Ç BANK NAME (PLEASE PRINT) BRANCH CITY STATE ZIP ROUTING NO. CHECKING ACCOUNT NO. SAVINGS ACCOUNT NO. PAY TO THE 012 ORDER OF XXXXXXX PROPANE $ MEMO 123456789 987654 0012 to my (our) account indicated below and the bank named below, hereinafter called BANK, to credit and/or debit the same to such accounts. Check # This authority is to remain in full force and effect until Xxxxxxx Propane has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Xxxxxxx Propane and BANK a reasonable opportunity to act on it. DATE XXXXXXX ACCOUNT NUMBER NAME(S)
Check Number. D. Came of the person to whom you wrote the check;
Check Number. Important Information
Check Number o I Will Pay With A Credit Card Total Amount of Check: Credit Card Type: MasterCard/VISA/American Express Name on Card: Credit Card Number: Expiration Date: Security Number: Zip Code of Credit Card Billing Address:
Check Number. This may be located between the routing number and the account number or after. (Do not include) If you have any questions, please contact us at: XXX.Xxxxxxxxxxx@xxxxxx.xxx or (000) 000-0000 Check Number Routing Number xxxx://xxx.xxxxxx.xxx/DAS/Financial/AcctgSys/Pages/ach.aspx
Check Number. It is understood that in the event the undersigned developer does not execute the agreement(s) within six months of notice of its availability for signature, the applicable deposit shall be forfeited to The Simsbury Water Pollution Control Authority. Owner Co‐Developer’s Information (if applicable) Owner’s name: Co‐Developer’s name: Mailing Address: Mailing Address: Telephone: Telephone: Owner’s written consent to the filing of the application (sign below): Statement of Accuracy and Permission: I hereby certify that all information submitted with this application is true and accurate to the best of my knowledge. The applicant understands that this application is to be considered complete only when all information and documents required by the Town have been submitted. Date Printed name of Owner Signature of Owner Appendix C: Instructions to Developers for Submittal Requirements under a DA Instructions to Developers for Submittal Requirements under a Developer’s Permit‐Agreement (DA) The Town of Simsbury WPCA requires the following items for processing a Developer’s Agreement for Sanitary sewers. Pre‐Application Meeting: The Town of Simsbury WPCA requires a pre‐application meeting to discuss the overall process, expected timelines, and determination of need for capacity analysis. Initial Application Submittal:
