Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: *********************************************************************************** High School Program Teacher: Please initial and indicate by marking an “X” in the box(s) for the course or courses you recommend this student be given credit for or for which you encourage proficiency testing. Students must earn at least a “B” to be given credit. Student is only eligible to earn “up to 12 articulated credits.” Sign and mail to: Xxxxxx X. XxXxxxx Xxxxx State College 0000 Xxxxx Xxxxxx NW North Canton, Ohio 44720 High School Program Teacher Initials Xxxxx State College (SSC) Course Number Xxxxx State College (SSC) Course Title SSC Credit Hours High School Grade AUT122 Automotive System & Engine Tech 4 High School Program Teacher’s Approval: Date: ********************************************************************************************
Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: *********************************************************************************** High School Program Teacher: Please initial and indicate by marking an “X” in the box(s) for the course or courses you recommend this student be given credit for or for which you encourage proficiency testing. Students must earn at least a “B” to be given credit. Student is only eligible to earn “up to 12 articulated credits.” Sign and mail to:
Please Print. (* An asterisk indicates that the information is required for processing.) E-mail Address: (Enter an active e-mail address for electronic communication purposes.) Spouse/Partner Name: *Billing Address: _ *City: *State: _ *Zip: _ *Primary Contact Phone: ( _) - Cell Phone: ( _) - Fax Number: ( _) _- *Emergency Contact Name: *Address: *City: _ *State: *Zip: *Emergency Phone Number: ( ) - Employer Name: Work Phone: ( ) - MDU Account Holder Name Signature Name that will appear on the xxxx-financially responsible person or entity Date: _ FOR OFFICE USE ONLY CSA ID# Processed by: Date: Continuous Service Agreement Form – Rev. 09-24-2015 Scan and return via - Email: xxxxxxxxxxxxxxx@xxx.xxx - Fax: 000-000-0000 or - Mail: Montana-Dakota Utilities Co., Attn: Customer Support, X.X. Xxx 0000, Xxxxx, XX 00000-0000 EXHIBIT A SERVICE LOCATIONS IDENTIFICATION NUMBER (OFFICE USE ONLY) COMPLETE XXXXXX XXXXXXX XXX. XX. XXXX, XXXXX 0.
Please Print. All fields required except e‐mail. Name: Birth Date: Height: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: ( ) E‐Mail: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE TO BE COMPLETED BY THE PARENT OR GUARDIAN IF PARTICIPANT IS UNDER THE AGE OF 18 ON THE DATE OF PROGRAM I am the parent or legal, court‐assigned guardian of the minor child whose name appears on this participation agreement. I have acknowledged receipt of the participation agreement, been given the opportunity to review the participation agreement, read its contents and am satisfied with, and in agreement with, the contents therein, having had the opportunity to discuss the same with the Provider and any third parties of my choosing. I, individually and as parent and/or guardian of my minor child do freely accept the terms of the participation agreement. I give my child permission to participate in the programs to be provided by Provider. My signature below reflects my agreement to fully release the Released Parties, as provided above, from any claim which I may have, and to release such persons on behalf of my child, for any claim the child may have. I further agree to indemnify the Released Parties for any claims of the child, or of any member of my or the child’s family, arising from the child’s enrollment or participation of the activities of the Provider. I further agree that my child shall be subject to the mandatory arbitration process described above. These agreements of release and indemnity include claims of negligence of a released party, including the negligence of any person or entity for whom a released party may be vicariously liable. Signature Date PARENT OR GUARDIAN SIGNATURE
Please Print. Name of purchaser Business Address City State Zip Code Purchaser’s Tax ID Number State of Issue Country of Issue If no Tax ID Number | FEIN | Driver’s License Number/State Issued ID Number | Foreign diplomat number Enter one of the following: | | | | 00-0000000 |_State of Issue: Number | Name of seller from whom you are purchasing, leasing or renting Seller’s address City State Zip code
Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: *********************************************************************************** High School Program Teacher: Please initial and indicate by marking an “X” in the box(s) for the course or courses you recommend this student be given credit for or for which you encourage proficiency testing. Students must earn at least a “B” to be given credit. Student is only eligible to earn “up to 12 articulated credits.” Sign and mail to: Xxxxxx X. XxXxxxx Xxxxx State College 0000 Xxxxx Xxxxxx NW North Canton, Ohio 44720 High School Program Teacher Initials Xxxxx State College (SSC) Course Number Xxxxx State College (SSC) Course Title SSC Credit Hours High School Grade DAS121 Dental Assisting Techniques I 3 DAS122 Dental Assisting Radiography 2 DAS123 Dental Assisting Techniques II 3 DAS124 Dental Assisting Materials 2 High School Program Teacher’s Approval: Date: ********************************************************************************************
Please Print. Name: High School: Graduation Date: Social Security Number Xxxxx State ID: Phone Student’s Signature: _ Date: ********************************************************************************** *
Please Print. Date Requested Type of Event Event Start time Event End Time Time should include set up and clean up. Applicant Name Address CITY/STATE/ZIP Employment Address Home phone Business Phone Cell phone Group or Organization and Address Number of Guests Attending Will Alcohol be served, brought, or distributed at the event ? Off-Duty Officer is needed for alcohol on premises! Officer must be paid “IN CASH” before the event begins. The fee of $38.00 per hour will be paid by the renter. Officer needed Start time: End time: Reservations must be made by persons 21 years of age or older.
Please Print. Groom’s/Bride’s Name Phone # Groom’s/Bride’s Name Phone # Permanent Mailing Address Date(s) of Function Location(s) Island Phone/Contact Number
Please Print. Date Company Name: Type of Service: Personal Business Contact Name(s): Address: City/Town: Province: Postal Code: Phone Number: (Bus.) (Res.) Financial Institution (FI): FI Account Number: FI Transit Number: - (branch - 5 digits; FI - 3 digits) Address: City/Town: Province: Postal Code: Authorized Signature(s): Canadian Health Food Association Attention: Accounts Payable 000 - 000 Xxxxxxxx Xxxx. Xxxxxxx, XX, X0X 0X0
