Check one box o I am attaching a cashier’s, personal or certified check, or have arranged for a wire transfer of immediately available funds to the Company, in an amount equal to the Aggregate Exercise Price. o In lieu of paying cash, I have elected to receive such lesser number of shares of Common Stock as determined pursuant to Section 1B(ii) of the attached Warrant. By: Name: Title:
Check one box. ¨ No performance target levels are applicable to this grant of Restricted Shares. ¨ The following performance target levels are applicable to this grant of Restricted Shares. In addition to the continued employment of Participant by (the “Employer”), the lapse of the forfeiture provisions referred to in Section 1 above shall also be conditioned upon the achievement by the Employer and its Subsidiaries, if any, of the following stipulated levels of earnings before interest, taxes, depreciation and amortization (“EBITDA”) for the measurement periods noted below: Measurement Date Measurement Period Percentage of Shares as to which Forfeiture Provisions Lapse EBITDA Target Level1 First anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA 2 Second anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA Third anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA Fourth anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA Fifth anniversary of Grant Date Preceding twelve calendar months 20 % % of Base EBITDA 1 In computing EBITDA for periods subsequent to , 20 , the Company shall use actual revenues for the relevant measurement period and the expenses used in determining Base EBITDA.
Check one box. ☒ All travel and meals are included as part of this Contract. No reimbursements shall be made to Contractor. ☐ The University shall reimburse travel and meals in accordance with the Contract and subject to University’s Travel Policy.
Check one box. ☒ All travel and meals are included as part of this Contract. No reimbursements shall be made to Contractor.
Check one box. □ 1 person □ 6 persons □ 2 persons □ 7 persons □ 3 persons □ 8 persons □ 4 persons □ Over 9 persons □ 5 persons Household/Family Income Summary Check one box □ $39,150 or below family income □ $65,250 or below family income □ $104,400 or below family income □ $137,850 or above family income Hispanic: Yes / No □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Pacific Islander Ethnicity Check one box □ American Indian/White □ Asian/White □ Black/White □ American Indian/Black □ Other/Multi-Racial I acknowledge that the Tech Lending Library Services are intended for library patrons who do not otherwise haveaccess to the equipment or services sufficient to meet the patron’s educational needs. To the best of my knowledge, the information above is correct and I fully understand that the information provided will be shared with the Library Services special grant reporting purposes, where names and identifiable information will be removed. Signature: Date: Email Address: Library card # Demographic Information (REQUIRED): Cell/Home #: Gender: Male/Female For Staff Completion: Technology Equipment: (Max 3 Devices Per Check-Out) [ ] Chromebook Serial Number Issued: [ ] Mi-Fi (up to 1 device) Serial Number Issued: [ ] Samsung Tablet Serial Number Issued: Device Tag Colors (last 4 digits of serial number) Yellow Green Orange Device Check-Out Date: Device Return Date: Tech Lending Library Borrowing Policy & Agreement Hayward Public Library Borrowing Policy for Long-Term Checkouts • Hayward Public Library’s technology equipment may be checked-out by Hayward residents whom otherwise do not have access to broadband internet or a computing device, who are 18 years and older, and complete this Borrowing Policy & Agreement Form. • A valid Hayward Public Library card number is required. • A borrower must read, understand, and sign this agreement before any technology equipment is checked- out. • The loan period for technology equipment check-out is 12 weeks. After the last day of the loan period, any late or unreturned devices will be disabled and rendered useless after the 2 day grace period. Technology equipment must be returned directly to the Downtown Library’s Account’s Desk. • All equipment and peripherals (boxes, power brick, etc.) must be returned on or before the due date and time indicated.
Check one box below to indicate whether the Owner will provide estimates of the Cost of the Work or whether the Architect will provide estimates of the Cost of the Work: [ «XX » ] Owner-provided estimates [ « » ] Architect-provided estimates
Check one box. Add this new payroll deduction plan to my account. Update my existing payroll deduction plan. Please change my investment allocation and the total amount deducted from my paycheck. Update my existing payroll deduction plan. Please change my investment allocation only. The total amount deducted from my paycheck will not change. Skip to Section 6. Stop my existing payroll deduction plan. I have contacted my employer to stop deductions from my paycheck. Skip to Section 7.
Check one box. Buyer understands that it is advisable to have a complete inspection of the Property by qualified professional(s), related to such matters as soil condition/compaction/stability, environmental issues, survey, zoning, availability of utilities, and suitability for Buyer’s intended purpose. [ ]
Check one box. The Authority will acknowledge your election and the applicable Accepted Allocation when executing the Agreement. Option 1 Customer elects to purchase ALL of the RNY Market Power listed under Accepted Allocation from the Authority: Customer Signature: SAMPLE Option 1 Allocation Information (will apply if ALL of the RNY Market Power that is part of the Awarded Allocation is purchased from the Authority) Awarded Allocation Accepted Allocation Contract Demand Term of Accepted Allocation Trustee Award Date Facility RNY Hydropower (kW): RNY Market Power (kW): Total (kW): RNY Hydropower (kW): RNY Market Power (kW): Total (kW): Contract Demand (kW)* 7 years (from the date of commencement of Electric Service) Date Customer City, NY *The value listed for the Contract Demand is subject to the Takedown Schedule, if any, attached to the Agreement as Schedule C. OR SCHEDULE A APPLICANT: Customer Name CONSOLIDATED FUNDING APP. No: APP ID Option 2 Customer elects to purchase NONE of the RNY Market Power listed under Accepted Allocation from the Authority: Customer Signature: Option 2 Allocation Information (will apply if NONE of the RNY Market Power that is part of the Awarded Allocation is purchased from the Authority) Awarded Allocation Accepted Allocation Contract Demand Term of Accepted Allocation Trustee Award Date Facility RNY Hydropower (kW): RNY Market Power (kW): Total (kW): RNY Hydropower (kW): RNY Market Power (kW): 0 Total (kW): Contract Demand (kW)* 7 years (from the date of commencement of Electric Service) Date Customer City, NY SAMPLE *The value listed for the Contract Demand is subject to the Takedown Schedule, if any, attached to the Agreement as Schedule C. FOR AUTHORITY USE ONLY: Authority Acknowledgement of Customer election: Accepted Allocation: kW RNY Hydropower purchased from the Authority: kW RNY Market Power purchased from the Authority: kW SCHEDULE B RECHARGE NEW YORK POWER COMMITMENTS The provision of RNY Power to the Customer is in consideration of, among other things, the commitments made by the Customer as provided for in this Schedule B.
Check one box x X (we) the undersigner(s) authorize Spring Hill College to HOLD excess federal student financial aid funds (if any) on my or my son/daughter/xxxx'x student account to be applied against future charges incurred. I (we) the undersigner(s) understand that this authorization may be rescinded in writing at any time. • q I (we) the undersigner(s) request the College to REFUND excess federal student financial aid funds (those amounts, if any, which exceed institutional charges) to me or my son/daughter/xxxx within 10 calendar days (or as otherwise required by federal guidelines) of the later of: the date the balance occurs or the first day of classes of the enrollment period. Any charges posting to my student account after a refund has been issued will remain my obligation. It is the responsibility of the students to stay informed, through the Regional Veterans Administration Office, regarding specific requirements for their educational benefit. If you have questions about VA educational benefits you should contact the VA office directly at 0-000-000-0000 or on the web at xxx.xx.xxx. I HAVE READ AND UNDERSTAND THE ABOVE LISTED REQUIREMENTS Student’s Signature Date
