PLEASE READ AND SIGN. Accounts. You request that Pershing Advisor Solutions open a brokerage account(s) in the names listed as account holders on this Agreement. You authorize Pershing Advisor Solutions to open additional brokerage accounts with the same registration using the address of record and other information that you provide in accordance with instructions received from your Authorized Advisor(s). You acknowledge that this Agreement (including the account Registration and the Terms and Conditions of the Agreement incorporated by reference into this Agreement as a material part thereof) governs each account opened under this Agreement (including any accounts opened as instructed by your Authorized Advisor[s]). You have received, read and understood this Agreement (including the Terms and Conditions of this Account Agreement, and your Margin Agreement with Pershing and you agree to be bound by its terms as amended from time to time. You understand that Pershing Advisor Solutions may send disclosures regarding your account(s), and that Pershing Advisor Solutions may modify them by sending updated disclosures. You agree that Pershing Advisor Solutions may provide information regarding this account to the Investment Advisor.
PLEASE READ AND SIGN. For the comfort of your pet, bedding can be used for your pet's boarding stay. Please understand that pets sometimes behave differently while boarding than at home. If you have provided bedding or would like the boarding team to use their bedding, you assume all risks. This includes any lost, ripped, or chewed bedding. By signing below you also acknowledge that if your pet were to chew and ingest some or part of bedding causing your pet to become sick, or require a life threatening intestinal surgery to remove the bedding, you assume all risks and financial responsibility as well. Please Indicate Bedding To Be Used: Owner's Provided Bedding: Y N Kennel Bedding: Y N Owner's Signature: Medical Illness Policy One of the advantages of boarding your pet(s) at a veterinary hospital is that veterinary attention is readily available should the need arise. If your pet(s) become ill, we will attempt to contact you or your emergency contact at the number listed above regarding your pet’s symptoms, treatment options, and estimate of additional costs. However, if your pet develops common symptoms of diarrhea or vomiting due to stress or change of diet while boarding we will treat the animal. Most treatments for these symptoms are inexpensive, but if there are other treatments that are necessary we will attempt to contact you first. Please indicate your wishes below should your pet(s) require treatment to relieve immediate discomfort or to resolve an important medical conditions. (CHECK ONE) Please perform whatever service the doctor deems necessary for the best care of my pet until someone can be reached. This includes only non-elective and necessary diagnostics. I authorize up to $ in medical care for my pet until someone can be reached. Do not administer any medical treatment until specific authorization is given. Any medical treatment that is needed for injuries that occur as a result of more than one pet in a run or injuries to themselves due to separation anxiety will be at the expense of the pet's owner. Please be aware that animals kenneled can become scared and can hurt themselves or other pets as a result. For example some pets can become food aggressive with other animals, if you are aware of this please inform our kennel staff, so we do not feed your dogs together. We do our best to prevent this, but if injury occurs the pet owner is responsible for the costs. We will treat injuries as needed regardless of what is checked above. Check Out Procedures: There i...
PLEASE READ AND SIGN. I have read, understood, and accepted the conditions of the WAIVER AND RELEASE OF LIABILITY printed above. Contractor’s Signature Print Name Date
PLEASE READ AND SIGN. You hereby request that Your Broker maintain a Brokerage Account in the name(s) listed on this Application. You acknowledge that you have received, read and understood the SWST Cash Account Agreement Section of the Customer Information Brochure and you agree to be bound by the terms and conditions of the Agreement that apply to your Brokerage Account, as amended and that you will contact Your Broker regarding any questions that may relate to your account. Under rule 14b-1(c) of the Securities Exchange Act, a broker is required to disclose to an issuer the name, address, and securities positions of our customers who are beneficial owners of that issuer’s securities unless the customer objects. If you object to the disclosure of such information, please check box: By signing this Application, you confirm your intention to reinvest cash credit balances held by SWST in your name, and you further confirm that this cash credit balance is being maintained in your account solely for the purpose of reinvestment. You acknowledge your understanding that cash balances of up to $250,000 are protected by the Securities Investor Protection Corporation (SIPC), but SIPC coverage is not available for funds maintained solely for the purpose of earning interest. For Office Use Only: Acct.# Office: Reg. Rep: Name for Filing: "Power of Attorney" not related to limited trading authorization will be accepted if it complies with the POA standards established by Southwest Securities, Inc. Certification of Taxpayer ID Number (Substitute W-9): Under penalty of perjury, you certify that (1) the number shown on this form is your correct taxpayer identification number, (or you are waiting for a number to be issued) and (2) you are not subject to backup withholding because (a) you are exempt from backup withholding, or (b) you have not been notified by the Internal Revenue Service (IRS) that you are subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified you that you are no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the acquisition or abandonment of secured property, contributions to an individual retirement arrangement (IRA), and payments other than interest and dividends), and (3) you are a U.S. person (including a U.S. resident alien). You understand that you must cross out item (2) above if you have been notified by the IRS that you are currently subject to...
PLEASE READ AND SIGN. I understand that Acelleron Medical Products or its assignee (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic. • Provider provides at least a three-year manufacturer’s compressor warranty on all its nebulizers. • I certify that the information provided by me and applying for payment under Title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct. • I understand that I am personally responsible to Provider for charges not paid in full by insurance coverage, deductible or co-pay responsibilities up to the maximum amount of $195. • I authorize release of all medical records in relation to the above referenced equipment. • I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits. • I agree that Provider may contact me in the future, via telephone, text, email or regular mail. • I have received the equipment in good working order, and been instructed on the proper and safe use of all the above listed equipment. • I certify that I have read the terms and conditions of this agreement (front and back) as well as, any attachments, and agree to their content. • I certify that I have been provided the Provider’s Patient Information Guide, Manufacturers User’s Manual for this equipment, the Client Xxxx of Rights & Responsibilities, HIPAA Notice of Patient/Guardian/Guarantor Por favor, xxx x xxxxx • Entiendo que los productos médicos Acelleron o su cesionario ("Proveedor") son propiedad y están manejados y no es de ninguna manera asociado con un hospital, la medicina o cualquier otra clínica. • El proveedor proporciona al menos una garantía del fabricante de compresor de tres años en todos sus nebulizadores. • Certifico que la información proporcionada por mí y la solicitud de pago bajo el Título XVIII (Medicare) de xx Xxx del Seguro Social de cualquier otro seguro es verdadera y correcta. • Yo entiendo que soy personalmente responsable al Proveedor por los cargos no pagados en su totalidad por la cobertura del seguro, las responsabilidades deducible o co-pago o, en ausencia de la cobertura del seguro, el saldo total del uso y costumbre cantidad / precio para este equipo hasta la cantidad maxima de 195$. • Autorizo la liberación de todos los registros médicos en relación con el equipo mencionado. • Solicito que xx xxxx un pago al proveedor por mi compañía de seguros, Medicaid, Medicare ...
PLEASE READ AND SIGN. I agree to abide by the Lending Services rules & policies, to pay all charges for any lost or damaged library materials accumulated on this card and to notify the Resource Center of any change of employment or loss of card. I understand I am responsible for all materials checked out on this card. Should I fail to return materials and/or promptly pay any charges incurred, I understand my loaning privileges will be suspended and my wages may be garnished for the replacement cost of the materials. Signature of Applicant Job Title Date Signature of Supervisor Job Title Date For RC Lending Use Only! Patron Number Issued: Requestor Type: Date: Issued by:
PLEASE READ AND SIGN. I have read, understood, and accepted the conditions of the WAIVER AND RELEASE OF LIABILITY printed above. CO�TRACTOR'S SIGNATURE
PLEASE READ AND SIGN. I, give my consent for psychotherapy services to be provided to , through INSIGHT COUNSELING PROFESSIONALS, PLLC. I understand that my sessions with Insight Counseling Professionals may either be authorized through my EAP or approved through a Managed Care Insurance program. This may mean that I can be seen either free of charge to me, or at reduced rates and/or copayments. I agree to pay all appropriate copayments as well as applicable deductibles and for services disallowed for any reason by my EAP/MC program or insurance company. I may or may not be financially responsible for appointments missed or canceled without 24-hour advance notice. I understand that I will forfeit my allotted EAP session(s) for each appointment missed or canceled without 24-hour advance notice. I agree that if I pay by check, my account will be debited electronically for both the face amount and returned check fee ($35.00) if it is returned unpaid. I also understand that I am financially responsible for any collections fees/court costs involved in collecting my past due account. I understand that if I am unable to keep a scheduled appointment, I will notify Insight Counseling Professionals within at least 24-hours of advanced notice. I understand that I am also financially responsible for all phone calls longer than 15 minutes. Payment is required at the time service is provided; however, insurance information will be obtained at the first session and insurance will be filed as a courtesy to me for sessions following the initial EAP sessions. Release and Assignment: I hereby authorize any plan benefits to be paid directly to Insight Counseling Professionals, PLLC. and I understand that I am financially responsible for non-covered services, including those for which authorization or payment has been denied, either by my EAP/Managed Care plan or other payer. If a claim is made by me or Insight Counseling Professionals to any insurance company or companies, or to any other third party payer, I do not object to the release by mail, fax, telephone, cell phone or computer modem, any records or other information about me, or my child, or the services which are provided, including without limitation, the complete case record, information concerning any personal, psychological and medical history, information concerning billing and payment for such services. I understand that modern communication modalities, such as cell phone, email, and fax, are subject to difficulties. I understand th...
PLEASE READ AND SIGN. I agree to abide by Xxxxxxx Service’s rules & policies, to pay all charges for lost or damaged materials accumulated on my authorized account and to notify Lending Services of any changes uncured. I understand my loaning privileges can be suspended and I also agree to be responsible for all costs of collections including Resource Center staff attorney fees, if applicable. I further agree that all charges and costs may be entered as a civil judgment against me and/or my organization. Employee Signature Job Title Date Supervisor Signature Job Title Date For RC Lending Use Only! Patron Number Issued: Requestor Type: Date: Issued by: Mail in original with signatures.
PLEASE READ AND SIGN. We must be able to completely trust each student to strictly follow instructions and obey the rules of good behavior. Any student who does not follow all instructions or disobeys the rules will not complete the tour with the group. You will be called to pick up your son/daughter. I have read this information and agree to be honorable and obedient in all that I do. Student Signature I understand that if my child breaks the rules, I will be required to pick him/her up and bring them home.
