Staff Use Only Sample Clauses

Staff Use Only. This Membership Application and Agreement shall not be binding until it is accepted by an authorized Pelican Lakes Representative’s Signature shown below. Accepted by: Pelican Lakes Resort & Golf Authorized Representative Authorized Signature Printed Name Date
Sample 1Sample 2Sample 3See All (4)
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Staff Use Only. Received by: Date Received: Accepted for processing by: Date Accepted: Not Accepted for processing: Date Refused:
Sample 1Sample 2
Staff Use Only. Application declined Application approved The above mentioned pet/s is/are approved by the lessor of the property stated in this agreement. This agreement now forms part of the General Tenancy agreement which includes the additional terms related to the pet/s and the tenant are now bound by the agreement set out in the application above as well as the General Tenancy Agreement. Authorisation on behalf of lessor Agent .................................................................................................................................... Signature ...........................................................................................................................
Sample 1
Staff Use Only. Have you ever belayed before: ⬜ Yes ⬜ No What belay device have you used? ⬜ ATC ⬜ Gri-Gri ⬜ Figure 8 ⬜ Other: Where did you learn how to belay? ⬜ Our facility ⬜ Another facility ⬜ A friend ⬜ Top Rope Test ⬜ Pass ⬜ Fail ⬜ Lead Test ⬜ Conditional Staff: Date: Non-Belayer Agreement: ⮚ There will be NO INSTRUCTING except by Xxxx Xxxxx Aquatic Centre staff. ⮚ At NO TIME will the non-belayer manage any part of the safety systems. ⮚ The non-belayer must abide by all the gym rules. ⮚ The designated belayer will accept the responsibility of the safety of the non-belayer. Name of Belayer Name of Non-belayer __ ___ Signature of Belayer Signature of Non-belayer __ ___ _ Date Date
Sample 1
Staff Use Only. Location: Monthly Dues: $17 First charge will appear on ■ Mission Center Building (hours of operation: M-F 5:30 am-10:00 pm Sat-Sun 7:30 am-8:00 pm) And will be payment for Automatic Payment Plan: ■ Payroll Deduction-paid in arrears Employee ID#_ __________ ____ ☐ Monthly ☐ Biweekly UCSF ID proxy card access allows entrance to the center. Access is not transferable; only the person pictured on the front of the ID will be allowed access to the center. Unauthorized use, sharing, alteration or duplication for any purpose will result in immediate confiscation of the card and may result in disciplinary or legal action. You agree to make payment of membership dues through payroll deductions. You affirm that you are an authorized holder of the account specified on this agreement. You acknowledge and agree that you are responsible for payment of all monthly fees and all updates to personal information. Written approval is required to cancel monthly dues. Cancellation requests must be submitted to Member Services by the 15th of the month to take effect the 1st of the following month. Membership does not automatically terminate upon separation from the University. Membership dues and fees are subject to change with a minimum of 30 days notice by the Fitness & Recreation Centers at UCSF.
Sample 1
Staff Use Only. RAPTOR Check: Date: Date: By: Athletic Director / Activities Director / Principal School Date: By: District Athletic Director (if applicable) Approved: Date:
Sample 1
Staff Use Only. Cleared to exercise Yes No Reason Staff Signature Date Name: _ Goals ZenRock Fitness Goals and Expectations What I’m trying to accomplish 1.
Sample 1
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Related to Staff Use Only

  • OFFICE USE ONLY Unit Size Requested Unit Number Targeted Move-In Date Date Received Time Received _C__o__k_a__t_o__P__a__r_k_v__i_e_w____________________________ _2__6_0___T__h_i_r_d__S__t_r_e__e_t__S__o__u_t_h__w__e__s_t_____________ _C__o__k_a__t_o_,__M___N___5_5__3_2__1_________________________ _P__h__:_(_3__2__0_)__9__0_5__-_2__8_7__4________________________ APPLICATION FOR OCCUPANCY Incomplete applications will be returned APPLICANT INFORMATION Applicant Name (Head of Household): First Middle Last Address: Street Address City State Zip Social Security Number: Date of Birth: [ ] Male [ ] Female [ ] Decline Applicant Phone #: Applicant Email: Alternate Phone #: Alternate Email: Emergency Contact: Name (Someone outside your household) Phone Email List All Other Household Members First MI Last Relationship to Head Date of Birth Male/Female/ Decline to Answer Social Security Number [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline Primary Language: Do you require an interpreter? [ ] Yes [ ] No How did you hear about this housing? [ ] Online [ ] Newspaper [ ] Local Agency [ ] Drive By [ ] Resident Referral [ ] Other What is the combined gross monthly income of all household members? $ ADDITIONAL HOUSEHOLD MEMBERS CURRENT HOUSING STATUS How long have you lived at your current address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: Do all adult household members live at this address?........................................................................................................................ [ ] Yes [ ] No If NO, include additional adult household’s current address and contact information on a separate piece of paper. PREVIOUS HOUSING STATUS Your previous address: How long did you live at your previous address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: List every state in which each household member has lived: ELIGIBILITY INFORMATION The following questions pertain to yourself and every member of your household who will occupy the unit. Check either Yes or No in response to each question. All questions must be answered; for those questions that do not apply, you are required to indicate so by answering “not applicable” or “n/a”.

  • USE ONLY AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: A NOTICE OF FEDERAL TAX LIEN (Check one box below.) RSI “1” no further review AI “0” Not a PPIA HAS ALREADY BEEN FILED RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA WILL BE FILED IMMEDIATELY RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs WILL BE FILED WHEN TAX IS ASSESSED Agreement Review Cycle: Earliest CSED: MAY BE FILED IF THIS AGREEMENT DEFAULTS Check box if pre-assessed modules included Originator’s ID #: Originator Code: Name: Title: INSTRUCTIONS TO TAXPAYER If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for: • Your name (include spouse’s name if a joint return) and current address; • Your social security number and/or employer identification number (whichever applies to your tax liability); • Your home and work, cell or business telephone numbers; • The complete name, address and phone number of your employer and your financial institution; • The amount you can pay now as a partial payment; • The amount you can pay each month (or the amount determined by IRS personnel); and • The date you prefer to make this payment (This must be the same day for each month, from the 1st to the 28th). We must receive your payment by this date. If you elect the direct debit option, this is the day you want your payment electronically withdrawn from your financial institution account. Review the terms of this agreement. When you’ve completed this agreement form, please sign and date it. Then, return Part 1 to IRS at the address on the letter that came with it or the address shown in the “For assistance” box on the front of the form. Terms of this agreement By completing and submitting this agreement, you (the taxpayer) agree to the following terms: • This agreement will remain in effect until your liabilities (including penalties and interest) are paid in full, the statutory period for collection has expired, or the agreement is terminated. • You will make each payment so that we (IRS) receive it by the monthly due date stated on the front of this form. If you cannot make a

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