For Office Use Only. Reviewed by: Existing transformer size: kVA Transformer upgrade required? Size Required: kVA Sec. wire owner: Sec. wire upgrade required? Size Required? Rev. Feb 2023 This institution is an equal opportunity provider and employer
For Office Use Only. Cash/Check/Charge VS/MC/AE Date: Paid: #: Name & Address: Card #: Exp: Code: MEDICAL MATTERS I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, > sign only those that are applicable.)
For Office Use Only. Broker/Dealer Name & Address Investor: ----------------------------- Investor #:__________________ [LOGO]ALPHACOM Tomorrow's Communications... Today! SUBSCRIPTION AGREEMENT FOR ALPHACOM, INC. COMMON STOCK ($5.00 PER SHARE) Persons interested in purchasing common stock of AlphaCom, Inc. must complete and return this Subscription Agreement along with their check or money order to: ALPHACOM, INC. 1035 XXXXXXXX XXXXXXXXX; SUITE I Akron, Ohio 44306, ("the Issuer") ("the Company") Subject only to acceptance hereof by the issuer, in its discretion, the undersigned hereby subscribes for the number of common shares and at the aggregate subscription price set forth below. An accepted copy of this Agreement will be returned to the Subscriber as a receipt, and the physical stock certificates shall be delivered to each Investor within thirty (30) days of the Close of this Offering. SECURITIES OFFERED - The Company is offering 1,900,000 shares (par value $.001 per share) at $5.00 per share. SUBSCRIPTION - In connection with this subscription the undersigned hereby subscribes to the number of common shares shown in the following table. NUMBER OF COMMON SHARES = ______________________ MULTIPLY BY PRICE OF SHARES x $5.00 Per Share ------------------------ AGGREGATE SUBSCRIPTION PRICE = $_____________________ Check or money order shall be made payable to ALPHACOM, INC. Exhibit 1.1 In connection with this investment in the Company, I represent and warrant as follows:
Examples of For Office Use Only in a sentence
Attestation / For Office Use Only Documents Received Certified CopiesMMDDYY YY KYC Verification Carried Out by (Refer Instruction I) Institution Details DateEmp.
Immediately upon completion of these updates, the Executive Assistant for Academic Affairs signs and dates the appropriate boxes in boxes in For Office Use Only section of Program Change/Delete/Addition Form.
For Office Use Only) Affix recent passport size photograph of the applicant duly signed across PLEASE FILL IN BLOCK LETTERS ONLY.
For Office Use Only Grant applications must be checked against the following criteria.
Signature Primary Account holder Investor Bank Name and Branch SB / CA / CC / SB NRE / SB NRO / Other BARODA PIONEER MUTUAL FUND For Office Use Only For Office Use Only I/We have read and understood the contents of the scheme related documents and hereby apply for allotment of units in the Scheme.
More Definitions of For Office Use Only
For Office Use Only. Date received: Booth #: Booth Size X = Total Sq. Ft. @ Rate $ Space Amount $ Web =$ HST= Total $ Salesperson: Show Management Authorization Date CONDITIONS OF EXHIBIT SPACE AGREEMENT
For Office Use Only. Total Amt Owed: Check #: Date: Deposit Rec’d? Refunded BHA Policy Manual Section IV Generator Society Hall Berne Room RESERVATION APPLICATION Information (must be filled out completely to confirm reservation): Event Date Event Time: From: To: *** (IMPORTANT: Include Preparation/Clean Up Time) *** Description of Event: # Attendees Will you need to use any of the Center’s audio visual equipment? If yes, please explain and list on back. Yes No Please list on back any decorations, additional equipment or furnishings you will be bringing for your event. Member Event Member Name: Mailing Address: City, State Zip: Phone Number Fax Email Non-Member Event Non-Member Name: Address: City, State Zip: Phone Number Fax Contact Phone (please also include an island or cell phone # for time close to event date) Email: Credit Card Number: (REQUIRED FOR NON-MEMBER RENTAL) Name on Card: Expiration Date: Card Code: (3-digit code on back of card) Billing Address: If you will be using audio visual equipment provided by the Association Center, please list below the equipment you will need, using the list in Appendix B of this policy: Please list here any interior/exterior decorations, additional furnishings or equipment you will be bringing to your event or other comments of which we should be aware. Important: Please indicate who will be in charge of the event on site (this person must be over 21 years of age). Contact Name: Address: Phone: Please return this completed form, the signed reservation agreement form and check with room fee to: Bald Head Association PO Box 3030 Bald Head Island, NC 28461 Checks should be made out to Bald Head Association, and
For Office Use Only. Recommendation: KEY EMPLOYEE, ISSUE HHRS NO INDIAN OR LOCAL INDIAN AVAILABLE, ISSUE WAIVER NON-REFERRAL (INDIAN) INDIAN(S) REFERRED: OTHER:
For Office Use Only. Account number: Date Received: Entered by: Confidentiality Agreement NOTICE ABOUT CONFIDENTIALITY OF CUSTOMER INFORMATION Chapter 182 of the Texas Utilities Code as amended in 2021 by House Bill 872 provides that a government-operated Municipal Utility District may not disclose personal information (customer’s address, telephone number, and social security number) in a customer’s account, or any information related to the volume or units of utility usage or amounts billed or collected for such utility usage, unless the customer elects to allow such information to be disclosed. The Utilities Code requires the District to provide notice of the customer’s right to allow disclosure of his or her information. Therefore, if you wish to allow disclosure of your personal information, please check the box below and return this form to the District.
For Office Use Only. Room: Total Amount Due $ (See page 2) *50% Deposit Balance Due $ Method of Payment Date Paid / / By $ Method of Payment Date Paid / / By **Damage/Clean-up Deposit (3rd floor - $250; Classroom - $100) Check Received Ch# Date Received / / By Deposit Returned Y N Amount Returned Date Returned / / By (Balance due MUST be received by DAAC at least two weeks prior to the event, along with linen order, room diagram, damage deposit (if applicable), or this contract becomes null and void.) Lessee’s Initials *50% of the total amount due is required to hold your date. **Damage/clean-up deposit is required. Checks will be held until event is over and the building is assessed for damage, extensive cleaning, and/or late departure.
For Office Use Only. Amount Paid: $ Date Received: Cash: Check #: Mastercard:
For Office Use Only. Date Received Time Received AM PM Confirmed Option on Confirmed Tax Amt Due on FICA Limit INSO Close on Control