ACKNOWLEDGEMENT AND AUTHORIZATION. By signing below, I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by the Company at any time after receipt of this authorization and throughout the course of my employment, if applicable. Signature: _ _ Date: _ First Name: _Middle Name: _ Last Name: _ Last Four Digits of SSN: __ _ Additional Information (for INTERNAL USE ONLY) In connection with my application for employment, I direct the following regarding my current employer: (please check one). Yes, my current employer may be contacted / No, my current employer cannot be contacted I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights (initials). I authorize Company and Agency to use email communication with me to provide me with notices and information regarding any report or use of such report. If I do not have an email address or do not wish to share it, then communication will be by U.S. Mail, which will result in slower communication. If you have any questions concerning this background screening content, please contact: AmericanChecked, Inc. (Agency) at (000) 000-0000. Printed Full Name: Signature: Date: _/ / Company Name: _ Current Address: City State Zip Previous Address City State Zip For identification purposes: Social Security No.: Date of Birth: Driver’s License No.: _ _ _ State of Issue: _ Supplemental State Disclosures Connecticut applicants/employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be because the information is substantially related to the job for which you are being considered/are currently occupying and to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered/are currently occupying Maine applicants/employees only: You may contact the Company to request the name, address and telephone number of the nearest unit of AmericanChecked designated to handle inquiries, which Company shall provide within 5 business days. You have the right to request and promptly receive a copy of any investigative consumer report requested by Company by contacting the nearest unit of the Consumer Reporting Agency directly. Maryland applicants/employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be because the information is substantially related to the job fo...
ACKNOWLEDGEMENT AND AUTHORIZATION. The Company approves the foregoing Custodial Agreement and authorizes the Approved MBS Custodian to act in accordance with the terms thereof. The Company agrees to be bound by the terms of the Custodial Agreement (including all Exhibits thereto) to the same extent as if a party thereto. The Company agrees to indemnify the Approved MBS Custodian for, and hold the Approved MBS Custodian harmless against, any loss, liability or expense in connection with, arising out of or in any way related to the transaction contemplated and relationship established by the Custodial Agreement, or any action or omission by the Approved MBS Custodian in connection with the Custodial Agreement, or any agent, broker or dealer employed by the Approved MBS Custodian hereunder, including the reasonable costs and expenses incurred in defending any such claim of liability, except that the Company shall not be liable for (i) any loss, liability or expense that is determined by a judgment of a court of competent jurisdiction that is binding on the Approved MBS Custodian, final and not subject to review on appeal, to be the direct result of acts or omissions on the Approved MBS Custodian's part constituting gross negligence or willful misconduct, or (ii) any claim that is based on the Approved MBS Custodian's warranty as provided in Section 8-306(3) of the New York Uniform Commercial Code. PULTE MORTGAGE LLC, a Delaware limited liability company By:________________________________ Name:______________________________ Title:_____________________________ EXHIBIT A TO CUSTODIAL AGREEMENT FORM OF LETTER TO APPROVED MBS CUSTODIAN To: _________________________, as Approved MBS Custodian Re: Pulte Mortgage LLC; Custodial and Collateral Agency Instructions Ladies and Gentlemen: Reference is made to the attached schedule relating to a letter/certification to a transfer agent/trustee for the issuance of the Security described more particularly therein, which Security is supported by a pool of residential mortgage loans and/or mortgage-backed securities including mortgage loans and/or mortgage-backed securities in which the undersigned as collateral agent (in such capacity, the "Collateral Agent"), acting under that certain Third Amended and Restated Security and Collateral Agency Agreement dated as of ____________, 2003, as amended, extended or replaced from time to time, holds a first priority perfected security interest. The attached schedule is (i) Delivery Schedule Form 11705 in the case of G...
ACKNOWLEDGEMENT AND AUTHORIZATION. The ACH Service is intended to be used to transmit Entries for which you are the “Originator” of the Entry as defined by the National Automated Clearing House Association (“NACHA”) Operating Rules (the “Rules”). If we determine that you are a “Third-Party Sender” or other designation under the Rules, we may require you to agree to additional terms, conditions and obligations by separate written agreement before approving your access to, or allowing you to continue to use, the ACH Service. By applying for or using the ACH Service, you authorize the Bank to transmit any Entry received by the Bank from you in accordance with the Rules and the terms of this Agreement and to credit or debit the amount of such Entry to the account(s) that you specify.
ACKNOWLEDGEMENT AND AUTHORIZATION. (1) FTMS hereby grants the Dealer a non-exclusive and non-sole right to conduct the following activities on terms and conditions of this Contract:
ACKNOWLEDGEMENT AND AUTHORIZATION. By checking the boxes and providing your electronic signature, you agree that you have read and understand the above contract terms of this Agreement, and agree with the interpretation of this contract as it has been explained to you. You also agree to the terms and recurring payments as stated above. You authorize SLC Muay Thai to submit and process payments through the debit or credit card or cards you have designated on your account. You hereby certify that you are the holder of the debit or credit card, or an authorized user of the account. Waiver and Release of Liability SLC Muay Thai 0000 x 000 x Xxx.3 (xxxxxxxxxxx@xxxxx.xxx) By checking the boxes and providing your electronic signature you agree to and acknowledge all terms of this release for all participants/members on your account and or as a parent or legal guardian of any participant/member minor [collectively hereinafter "participant" or "participants"] that is less than 18 years, old who wish to participate in practice sessions or events sponsored or conducted by Punisher Muay Thai Kickboxing and Fitness. In consideration of being allowed to participate in any way in the martial arts training, sports programs, and other events and activities conducted by SLC Muay Thai, you:
ACKNOWLEDGEMENT AND AUTHORIZATION. By signing below, I authorize COB and BPL, or its authorized agents to obtain or prepare consumer reports or investigative consumer reports about me. I acknowledge receipt of a copy of the federal notice entitled A Summary of Your Rights under the Fair Credit Reporting Act and certify that I have read this Disclosure and Authorization as well as the summary document explaining my rights under the Fair Credit Reporting Act. Location: I://drive – Volunteers – Forms & Applications
ACKNOWLEDGEMENT AND AUTHORIZATION. By signing below, I certify and acknowledge that the Company is authorized to defer payment of shares of Stock as indicated above and that I will be responsible for any taxes due as described in the Plan. I further acknowledge that my RSU Award and the shares of Stock related thereto are governed by the terms and conditions of the Plan document. The above acknowledgement and Participant Information is true, accurate and complete. Signed: _________________________________________________ Date: ____________________ As Plan Administrator, I hereby acknowledge receipt of this form.
ACKNOWLEDGEMENT AND AUTHORIZATION. CLIENT and JFMEL acknowledge that each has read and agrees to the Terms and Conditions printed on the reverse side of this document that are incorporated herein and made a part of this Agreement. Per: Title: Date:
ACKNOWLEDGEMENT AND AUTHORIZATION. I have read, understand, and agree to the above policies listed on page 1 and page 2. Regardless of any insurance I may have, I am ultimately responsible for payment of any professional services rendered. I authorize the release of medical information necessary to process a claim for benefits under my policy and assign payment of my insurance benefits to Waterview Dentistry. If my account should become delinquent, I agree to pay the costs of collection, including agency fees, attorney fees, and court costs. Signature of Patient or Parent if Minor (or legal Guardian) Date: HIPPA Notice of Privacy Practices Xxxx Xxxxx, DDS 0000 Xxxxxxxx Xxxx Xxx. 000 McKinney, Texas 75071 (972) 364‐5133 Fax: (972) 346‐5131 THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
ACKNOWLEDGEMENT AND AUTHORIZATION. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by UUCP at any time after receipt of this authorization and throughout the course of my relationship with UUCP, if applicable. Signature: Date: Print Full Legal Name: SSN: Birthdate: Current Address: Current email:
