SIGN AND DATE. All sums payable under the Amended and Restated Executive Salary Continuation Agreement, by reason of my death shall be paid to the Primary Beneficiary(ies), if he or she survives me, and if no Primary Beneficiary(ies) shall survive me, then to the Secondary (Contingent) Beneficiary(ies). This beneficiary designation is valid until the participant notifies the bank in writing. Executive Date
SIGN AND DATE. This Beneficiary Designation Form is valid until the participant notifies the bank in writing. Executive Date
SIGN AND DATE. This Beneficiary Designation Form is valid until the participant notifies the bank in writing. ___________________________ ______________________________ Xxxxxxx Xxxx Hertha Date
SIGN AND DATE. 8. On an annual basis, for the most recent year only, select the appropriate answer (yes or no) or write in the appropriate response indicating if you have been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.
SIGN AND DATE. The information on this form is true and correct to the best of my knowledge. I agree to participate in the Settlement. I authorize any dealership that serviced my vehicle to release records to the Settlement Administrator as needed to assist in the payment of my Claim. To the extent I am seeking reimbursement for a Qualifying Loss for which I do not have documentation, I attest as follows: ☐ Cash Payment for Repairs Performed at Hyundai or Kia Dealership: I hereby swear under penalty of perjury under the laws of the United States that I had repairs performed at an authorized Hyundai or Kia dealership (name of dealership) and paid $ in cash but I do not have a cash payment receipt from the dealership showing payment. ☐ Cash Payment in General: I hereby swear under penalty of perjury under the laws of the United States that I paid for (description of reason for payment) and paid $ in cash but I do not have a cash payment receipt showing payment. Along with this attestation, I am submitting a valid corresponding final invoice or repair order and proof of withdrawal of cash from a bank or credit union. ☐ Unrecovered Class Vehicle: I hereby swear under penalty of perjury under the laws of the United States that I experienced a Qualifying Theft of my Class Vehicle on _ (Date) and as of today, I still have not recovered my Class Vehicle. (Note: In the event a Class Vehicle is recovered following the submission of this Claim, but before payment is issued from the Common Fund, you must notify the Settlement Administrator of the recovery and the condition of the recovered Class Vehicle.) Signature: Date: ‐ ‐ MM DD YYYY
SIGN AND DATE. By signing below, the Tenant acknowledges receipt of a complete copy of this Rental Agreement with all blanks filled in. LANDLORD TENANT SIGNATURE(S) {{_es_:sender:signat ure}} {{_es_:signer1:signature}} Legerity Services, Inc., President {{_es_:signer2:signature}} {{_es_:signer3:signature}}
SIGN AND DATE. .. An assessment of suitability of the course Additional support requirement The learning aims of the course The entry requirements of the course
SIGN AND DATE. I have read the above and agree to abide by the payment and terms and conditions as outlined. I understand that this form confirms my reservation. I accept that from now on charges will be imposed for cancelled reservations. Signature: Date: HYATT REGENCY SARASOTA TERMS AND CONDITIONS OF RESERVATION Exhibit reservation does not include: drayage, decoration, labor, guard/security service, cleaning or janitorial services, electrical (unless pre-arranged), gas or water. Hyatt Regency Sarasota Release of Liability: Exhibitor shall be fully responsible to pay for any and all damages to property owned by Hyatt Regency Sarasota, its owners or managers which result from any act or omission of Exhibitor. Exhibitor agrees to defend, indemnify and hold harmless, Hyatt Regency Sarasota its owners, managers, officers or directors, agents, employees, subsidiaries and affiliates, from any damages or charges resulting from Exhibitor’s use of the property. Exhibitor’s liability shall include all losses, costs, damages, or expenses arising from, out of, or by reason of any accident or bodily injury or other occurrences to any person or persons, including the Exhibitor, its agents, employees, and business invitees which arise from or out of the Exhibitor’s occupancy and use of the exhibition premises, the Hotel or any part thereof. Sign and Date I have read the above and agree to abide by the terms and conditions as outlined.
SIGN AND DATE. This Beneficiary Designation Form is valid until the participant notifies the bank in writing. /s/ Xxxx X. Xxxxx 12/15/2008 Executive Date *SECTION VI TO BE COMPLETED ONLY BY PARTICIPANTS WHO RESIDE IN THE FOLLOWING STATES: (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, and Wisconsin).
SIGN AND DATE. Notice to Buyer: Do not sign this Enrollment Agreement before you read it or if it contains any blank spaces. You are entitled to an exact copy of this signed Enrollment Agreement. Keep all documents regarding enrollment and financial obligations to protect your legal rights. As a requirement of my enrollment I am providing proof of my High School Diploma or GED; however, if I am unable to provide proof of this document my signature below certifies that I have earned the document and have met that entrance requirement. Photocopy of ID card or U.S. Driver’s License issued by Federal, State or Local agency or entity is required with this enrollment agreement. ID must contain information such as name, date of birth, gender and address. I have read the terms and conditions contained in this Enrollment Agreement and have received the current course catalog. I understand that for this contract to be binding, the contract must be signed by myself and the school official. Contract changes may be made only by written consent of both parties. STUDENT SIGNATURE: Date:
