Mail to. Phone/Fax: Local 1081 The Labourers’ Multi-Local Welfare Trust Fund c/o Global Benefit Plan Consultants Inc. 000 Xxxxxx Xxxxxx, Toronto, ON M3H 1V2 Tel: (000) 000-0000 Fax: (000) 000-0000 Local 1081 Labourers’ Local 1081 c/o LIUNA Local 1081 Tel: (000) 000-0000 - Training Training Trust Fund 000 Xxxxxxxx Xxxxxx Cambridge, ON N3H 2N1 Fax: (000) 000-0000 Local 1089 Labourers’ Local 1089 (Sarnia) Benefit Trust Fund All remittances to: c/o LIUNA Local 1089 Tel: (000) 000-0000 0000 Xxxxxxxxxxxxx Xxxxxx Xxxxxx, XX X0X 0X0 Fax: (000) 000-0000 Local 1089 - GRSP Labourers’ Local 1089 G.R.S.P. Fund Local 1089 - Training The Administrator of Local 1089 Training Fund NOTES
Mail to. The Research Foundation for The State University of New York Office of Grants Management Stony Brook University Stony Brook, NY 11794-3366
Mail to. Bridges Graduate School, 0000 Xxxxxx Xxxxxx Xxxx, Xxxxxx Xxxx, XX 00000 or email the completed form to: XxxxXxxxxxXxxxxxxxxx@Xxxxxxx.xxx Legal Name: (Last, First Name,Middle Name) Other Names that may appear in your academic record: Mailing Address: City: State: Zip: - Country: Permanent Address: If Different Address: City: State: Zip: - Country: Primary Phone #: Other Phone #: Email: Xxxxxxx will use this email for almost all communications. Birthdate: mm dd yyyy Social Security Account Number: See “Use of the Social Security Number: “ at the bottom of this application.
Mail to. LadyBagpiperPat PO Box 470243 Lake Monroe, Fl 32747-0243 Or, e-mail this completed form to xxx@xxxxxxxxxxxxxxx.xxx
Mail to. Mt. Xxxxx Club, PO Box 73, Bellingham, WA 98227. Release, Hold Harmless and Indemnity Agreement I hereby state that I wish to participate in activities offered by the Mount Baker
Mail to. The Board of Regents of The University System of Georgia Academic Common Market Coordinator 000 Xxxxxxxxxx Xx., XX Xxxxx 0000 Atlanta, GA 30334 GEORGIA ACADEMIC COMMON MARKET APPLICATION Certification of Georgia Residency Applicant Information Full Name: Last First M.I. Birth Date: Place of Birth: Street Address Apartment/Unit # City State ZIP Code Street Address Apartment/Unit # City State ZIP Code Address: Parents’ Address: Home Phone: Alternate Phone: Email High School Attended: Last 4 digits of SSN XXX-XX- Academic Common Market Program Information Institution State Major / Program Degree (eg. BA, BS) Concentration Requesting certification starting semester Fall Spring Summer Have you been fully admitted to the major without conditions YES NO Will you enroll fulltime? YES NO Supplemental Information Current Residence Maintained Continuously since (Month/Year) Most Recent Driver’s License Issued by Which State: Automobile(s) (if Any) Registered In Which State: Dates of last full-time employment (Inclusive Dates) State Company If Married, Name of Spouse and Address If Spouse employed, where Year and State for which last State Income Tax Return was filed State of Residence Claimed on last State Income Tax Return State of Residence Claimed for whole or part year Last year Homestead Exemption was claimed on a home in State/ Residence In which State were you last registered to vote Date Military Service Home of Record Notary Signature I do solemnly declare and affirm under penalties of perjury, that the information I provided in this application is true and accurate for the purpose of assisting the said official in determining my legal residency status; and that all supporting documents attached hereto are true and complete copies of the original documents. Sworn to and subscribed before me this day of , 20 Applicant Signature Date Notary Public Signature Date Certificate of Residency Certification The following certificate must be executed by a Judge of the Highest Court in the county of your legal residence. (Contact your local county courthouse and ask for the Superior Court Judge, they should guide you from there) Based on the above information, I hereby certify that, in my opinion (Student Name) is and has been a legal resident of the State of GEORGIA for the past twelve (12) months or more. Signature of Official
Mail to. Early Years Funding Co-ordinator, Nottingham City Council, Access and Learning, Children and Adults, Early Years Team, Loxley House, Station Street, Nottingham NG2 3NG Email to: xxxxxxxxxx@xxxxxxxxxxxxxx.xxx.xx SIGNED ON BEHALF OF THE LOCAL AUTHORITY BY A DULY AUTHORISED SIGNATORY OF NOTTINGHAM CITY COUNCIL, ACCESS AND LEARNING, CHILDREN AND ADULTS, EARLY YEARS TEAM: Signed: .................................................................................................. Date: .....................................
