Client Contact Information. Please provide the Contact Information for those involved in the administration of your plan. NOTE: Only one person may be the Primary contact for each section. Contact #1: Name: Title: Phone: Fax: Email: Primary Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Additional Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding (continued) Contact #2: Name: Title: Phone: Fax: Email: Primary Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Additional Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Contact #3: Name: Title: Phone: Fax: Email: Primary Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding Additional Contact for: Implementation Case Management Privacy officer HR/Benefit manager Executive Web portal Eligibility Billing Claims Funding
Client Contact Information. The contact information of Client(s) is set forth below: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client agrees to immediately update Broker of any changes to the above referenced information. SPECIAL STIPULATIONS: The following Special Stipulations, if conflicting with any exhibit, addendum, or preceding paragraph, shall control: Additional Special Stipulations are □ or are not □ attached. BY SIGNING THIS AGREEMENT, BUYER ACKNOWLEDGES THAT: (1) BUYER HAS READ ALL PROVISIONS AND DISCLOSURES MADE HEREIN; (2) BUYER UNDERSTANDS ALL SUCH PROVISIONS AND DISCLOSURES AND HAS ENTERED INTO THIS AGREEMENT VOLUNTARILY; AND (3) BUYER IS NOT SUBJECT TO A CURRENT BUYER BROKERAGE AGREEMENT WITH ANY OTHER BROKER. RECEIPT OF A COPY OF THIS AGREEMENT IS HEREBY ACKNOWLEDGED BY BUYER. The above Agreement is hereby accepted, o’clock .m., on the date of . Broker Buyer’s Signature Address: Print or Type Name Buyer’s Signature MLS Office Code Brokerage Firm License Number Print or Type Name Broker’s Phone# & FAX# By: Broker or Broker’s Affiliated Licensee Print or Type Name Agent’s Georgia Real Estate License Number Email Address:
Client Contact Information. The contact information of Client(s) is set forth below: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client agrees to immediately update Broker of any changes to the above referenced information.
Client Contact Information. The Contact Person is the person within the Client organization who is selected by the Client to authorize user access to Employer Online Services. Contact Person: Contact Telephone Number: Contact E-mail Address:
Client Contact Information. The contact information of Client(s) is set forth below: _Buyer's Name Here Client Name _Buyer's Mailing Address Address for Receiving Notice Business Telephone: Buyer's Work Number Home Telephone: Buyer's Home Number Cell Phone: Buyer's Cell Number Facsimile Number: Buyer's Fax Number E-mail Address: Buyer's E-mail Address _Spouse or Partner's Information Client Name Address for Receiving Notice Business Telephone: Home Telephone: Cell Phone: Facsimile Number: E-mail Address: Client agrees to immediately update Broker of any changes to the above referenced information. SPECIAL STIPULATIONS: The following Special Stipulations, if conflicting with any exhibit, addendum, or preceding paragraph, shall control: This Buyer Brokerage Agreement is filled out only as an example. This document will be properly filled out and signed by all parties involved. Please let us know if you have any questions or concerns regarding this document. BY SIGNING THIS AGREEMENT, BUYER ACKNOWLEDGES THAT: (1) BUYER HAS READ ALL PROVISIONS AND DISCLOSURES MADE HEREIN; (2) BUYER UNDERSTANDS ALL SUCH PROVISIONS AND DISCLOSURES AND HAS ENTERED INTO THIS AGREEMENT VOLUNTARILY; AND (3) BUYER IS NOT SUBJECT TO A CURRENT BUYER BROKERAGE AGREEMENT WITH ANY OTHER BROKER. RECEIPT OF A COPY OF THIS AGREEMENT IS HEREBY ACKNOWLEDGED BY BUYER. The above Agreement is hereby accepted, o’clock .m., on the date of . _Xxxxxx Xilliams Realty-Peachtree Battle Broker Buyer’s Signature Address: 0000 Xxxxxxxxx Xx. Xxxxx X Buyer's Name Here Print or Type Name Xxxxxxx, XX 00000 Buyer’s Signature KWPB01 H-54627 Spouse or Partner Name Here MLS Office Code Brokerage Firm License Number Print or Type Name Broker’s Phone#_000-000-0000 & FAX#_000-000-0000 By: Broker or Broker’s Affiliated Licensee The Castleberry Team Print or Type Name Agent's License Number Agent’s Georgia Real Estate License Number
Client Contact Information. The contact information of Client(s) is set forth below: Client Name: Xxxx Xxxxxxx Address for Receiving Notice: 000 Xxxxxxx Xxxxx Carson, GA 33333 Business Telephone: 000-000-0000 Home Telephone: 000-000-0000 Cell Phone: 000-000-0000 Facsimile Number: 123-555-9670 EXCLUSIVE SELLER LISTING AGREEMENT
Client Contact Information. Client contact information is set forth in Exhibit A attched hereto and made a part hereof.
Client Contact Information. Please fill out the following information, which will be used by our deployment & accounting teams. Billing Contact Title Address 000 Xxxx Xx City, State Zip Dayton, KY 41074 Phone Email Project Contact Title Phone Email *Executive Sponsor (Head of School, Business Manager/CFO, etc.)
Client Contact Information. CLIENT shall provide a valid, confidential FAX number on the standard PATHGROUP Provider Fax Verification Form.
Client Contact Information. For purposes of this Article XI, the Service Provider shall contact the following: EMS Division Chief Director of Finance City Attorney Kenosha Fire Department Municipal Building Xxxx 000 Xxxxxxxxx Xxxxxxxx Xxxx 000 0000 00xx Xxxxxx 000 00xx Xxxxxx 000 00xx Xxxxxx Xxxxxxx, Xxxxxxxxx 00000 Xxxxxxx, Xxxxxxxxx 00000 Xxxxxxx, Xxxxxxxxx 00000 000-000-0000 000-000-0000 000-000-0000
