DD YYYY. Sex: Male Female (Choose One) Phone: - - Alt Phone Email: Home Address (must be within an AFMA Ambulance Service Area) Facility Name (Optional): Street Address: Mailing Address (If different from above): City: State: Zip Code: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Name: Your name must match your primary insurance card exactly Social Security Number: - - Date of Birth: MM - DD - YYYY Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Signature: SPOUSE DEPENDENT CHILD OTHER SPOUSE DEPENDENT CHILD OTHER Name: Your name must match your primary insurance card exactly Social Security Number: - - Date of Birth: MM - DD - YYYY Sex: Male Female (Choose One)) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Signature: Name: Your name must match your primary insurance card exactly Social Security Number: - - Date of Birth: MM - DD - YYYY Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Signature: SPOUSE DEPENDENT CHILD OTHER Name: Your name must match your primary insurance card exactly Social Security Number: - - Date of Birth: MM - DD - YYYY Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Signature: Arizona Fire & Medical Authority 18818 N. Spanish Xxxxxx Xxxxx, Xxx Xxxx Xxxx, Xxxxxxx 00000 • P (000) 000-0000 • F (000) 000-0000 • xxx.xxxx.xx.xxx ARIZONA FIRE & MEDICAL AUTHORITY Protecting lif...
DD YYYY. Note: Enter the estimated completion (End) date for support under this agreement.
DD YYYY. Agreement This Agreement (the “Agreement”) is entered into as of the date indicated above between Fidelity Charitable® and the Investment Advisor firm being hired to provide investment advisory services indicated above (the “CIAP Advisor Firm”).
DD YYYY. In consideration of the lender's reduction of the interest charged the borrower's account, the United States of America, acting thorough the Farm Service Agency of the United States Department of Agriculture (FSA) pursuant to the Consolidated Farm and Rural Develo.pment Act agrees that in accordance with and subject to the conditions and requirements in this agreement it will reimburse interest to the lender at a maximum of 4 percent per annum of the average daily principal balance, subject to limitations in FSA regulations. The full amount of interest assistance payments made by FSA to the lender will be passed on to the borrower. The initial period of this agreement begins (c) and ends (d)
DD YYYY. I will meet the responsibilities of a clinical supervisor as outlined in the “Clinical Supervisor Responsibilities” form. This includes meeting one hour face-to-face per week, regardless of hours Student's Name: , has spent with clients. To the degree that I am able, I will try to structure Student's Name: , time so that he/she will have a minimum of 40 hours of face-to-face contact with clients. I understand that this contact can include co-therapy, individual, group, and/or family therapy done by Student's Name: . I will complete periodic evaluations of Student's Name: and, after discussing it with the student, I will provide the student with the original to submit into Blackboard. I am aware that I will speak with the faculty supervisor at least once per term.
DD YYYY. The CM shall act as a consultant to UC Xxxxx Health, Facilities Design and Construction, to perform Construction Management Services as required and authorized by University pursuant to the Services Scope described in Exhibit M. University will authorize the CM to perform specific services by the issuance of a written Authorization(s) on the form contained in the Exhibits. Each written Authorization will state the specific project and services to be performed, the schedule for their completion, and the method of compensation, which shall be in accordance with Article 5.
DD YYYY. The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of $ beginning - - MM DD .
DD YYYY. During this time, I agree to become familiar with the policies and procedures of the
DD YYYY. Unless extended, the contractual employment shall automatically cease on the completion of the said period. The contractor will be paid salary package per month shall b as under: Gross Salary 14529/- Employee Share 1740/- Salary Payable 12789/- 2 The contractor will be required to deposit a sum of Rs. 8218/-(Rupees Eight Thousand Two Hundred Eighteen only) as security for faithful execution of the contract which will be recovered from the salary for the first month. This amount of Rs. 8218/- will be refunded on completion of the contract or in case of default in the fulfillment of terms and conditions of the contract or if he/she leaves employment without proper resignation, the amount of security deposit, so recovered, will be forfeited. 3 Working hours and holidays will be as per norms of the department in which deployed. The Contractor will be entitled to one day's Casual Leave during a month. However, the leave shall be availed of after prior sanction of the competent authority.
DD YYYY. I will meet the responsibilities of a clinical supervisor as outlined in the “Clinical Supervisor Responsibilities” form. This includes meeting one hour face-to-face per week, regardless of hours Student's Name: , has spent with clients. To the degree that I am able, I will try to structure Student's Name: , time so that he/she will have a minimum of 240 hours of face-to-face contact with clients. I understand that this contact can include co-therapy, individual, group, and/or family therapy done by Student's Name: . In addition, I will support Student's Name: , in conducting two taped sessions or provide & document live supervision. I will complete periodic evaluations of Student's Name: , and, after discussing it with him/her, will enter the evaluation into LiveText. I am aware that I will need to have quarterly consultation via phone and/or email with the faculty supervisor. I understand that the faculty member will provide Student's Name: , with group supervision an average of 1.5 hours per week. I, Site Director's Name: agree to give permission to Student's Name: , as the site director of Site's Name: , to release confidential information to Off-Site Supervisor's Name: . Supervisor's Signature: . Date: .
