Street Address. The physical address where the commercial property is accessible is a necessary item for this contract’s effect. This information should include the building number, street, and unit number of the commercial space along with the city, state, and zip code. Once this contract is signed, this will be the premises the Lessee shall pay to occupy. (7)
Street Address. Documentation of the physical location for the commercial real estate must be included. (6)
Street Address. Enter the physical street address of the software vendor. This MUST be a physical address. If a P. O. Box is entered in this area, the document will be rejected and returned for correction.
Street Address. Marital Status: If visitation rights exist, please complete Special Pickup Instructions on page 3 Home Address: Street Address City State Zip Code Residential Subdivision: Telephone: Home: Area Code Number Work: Area Code Number Cell: Area Code Number Email Address: Driver’s License: State Issued Number Soc. Security #: Employer Name: Employer Address: Street Address City State Zip Code Residential Subdivision: Telephone: Home: Area Code Number Work: Area Code Number Cell: Area Code Number Email Address: Driver’s License: State Issued Number Soc. Security #: Employer Name: Employer Address: Street Address City State Zip Code Work Hours: City State Zip Code Work Hours: CHILD INFORMATION Child’s Name: Include child’s last name if different than parents Preferred Name: Address:
Street Address. City: ...................................... State: ............... Zip: ......................
Street Address. 3. The Member agrees that he shall only make use of the water provided under this Agreement for the following purposes and for no other purpose:
Street Address. TELEPHONE: AREA CODE: ..................................... NUMBER............................................................... FACSIMILE: AREA CODE: ....................................... NUMBER............................................................... E-MAIL ADDRESS (IF AVAILABLE): ........................................................................................................................ NAME OF CONTACT PERSON: .............................................................................................................................. CELL PHONE NUMBER OF CONTACT PERSON: .................................................................................................. Has a valid original tax clearance certificate been submitted YES / NO Income Tax Number ................................................................................... Name of taxpayer ................................................................................... Identity number of taxpayer (if applicable) .................................................................................... Employer's PAYE registration number (if applicable) .................................................................................... Is a CIDB certificate enclosed? Company or CC Registration No Are you the accredited representative in South Africa for the goods / services offered by you? YES / NO / NOT APPLICABLE YES / NO / NOT APPLICABLE DELIVERY BASIS: Is the delivery period firm? YES / NO Period required for delivery after receipt of order (days) Is the price (inclusive of VAT) firm? YES / NO Discount offered: Conditional/Unconditional If conditional, state condition: Is offer strictly to specification/terms of reference YES / NO If not to specification/terms of reference. Please state deviation(s) if any: ................................................................ .................................................................................................................................................................................... BANK DETAILS (IF APPLICABLE): BANK NAME: BRANCH: BRANCH CODE: ACCOUNT HOLDER: ACCOUNT NUMBER: ACCOUNT TYPE: OFFICAL STAMP FROM BANK ……………………………………………………….. AUTHORISED BANK OFFICIAL AUTHORISED SIGNATURE: .......................................................................................................................................... NAME: .................................................................................
Street Address. Marital Status: If visitation rights exist, please complete Special Pickup Instructions on page 3 Home Address: Street Address City State Zip Code Residential Subdivision: Telephone: Home: Area Code Number Work: Area Code Number Cell: Area Code Number Email Address: Driver’s License: State Issued Number Soc. Security #: Employer Name: Employer Address: Street Address City State Zip Code Residential Subdivision: Telephone: Home: Area Code Number Work: Area Code Number Cell: Area Code Number Email Address: Driver’s License: State Issued Number Soc. Security #: Employer Name: Employer Address: Street Address City State Zip Code Work Hours: City State Zip Code Work Hours: CHILD INFORMATION Child’s Name: Include child’s last name if different than parents Nickname: 2nd Child’s Name: : Include child’s last name if different than parents Nickname: Gender: Date of Birth: / / Comments: Gender: Date of Birth: / / Comments: Program Request Full Time (5 day) Part Time (3 day – M,W,F) Part Time (2 day – Tu,Th) Class Avail. All classrooms 2’s, 3’s, 4’s, 5’s 2’s, 3’s, 4’s, 5’s Program Request Full Time (5 day) Part Time (3 day – M,W,F) Part Time (2 day – Tu,Th) Class Avail. All classrooms 2’s, 3’s, 4’s, 5’s 2’s, 3’s, 4’s, 5’s
Street Address. 10.7 The Bursary Recipient chooses for this agreement its domicilium citandi et executandi and address for any notices as follows:
Street Address. City,State & Zip Code: The Applicant is the (choose one) ¨ Trustee ¨ Plan Sponsor/Employer ¨ Named fiduciary of the following Plan(s): Such Plan(s) is/are intended to meet the requirements of the following sections of the Internal Revenue Code: ¨ 401(a) ¨ 401(k) ¨ 403(b) ¨ 414(d) ¨ 457(b) ¨ 457(f) ¨ Other The Applicant hereby applies for a PRIAC [Investment Agreement (a group annuity contract)] with the following investment product(s): This Application will be attached to and form a part of the [Investment Agreement]. WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. The undersigned individuals represent that they have the requisite power and authority to apply for [a(n) Investment Agreement] on behalf of the Plan(s). By By Title Title By By Title Title GA-2008 APP (DC)
