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: __ _ 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: _ Massachusetts applicants/employees only: The precise nature and scope of any investigative consumer report will be the same as described in Background Check Disclosure. You have a right to obtain a copy of any investigative consumer report upon request from AmericanChecked Inc., 0000 Xxxxx Xxxxx Xxx. Ste. 120, Tulsa OK 74105, telephone 000-000-0000. New Jersey applicants/employees only: The precise nature and scope of any investigative consumer report will be the same as described in Background Check Disclosure. You have a right to obtain a copy of any investigative consumer report upon request from AmericanChecked, Inc. 0000 Xxxxx Xxxxx Xxx., Ste. 120, Tulsa OK 74105, telephone 000-000-0000. For Oregon 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. For Washington ...
ACKNOWLEDGEMENT AND AUTHORIZATION. I hereby certify that I have read and understand the items on this appointment form and that my answers are true and complete to the best of my knowledge. I have been advised that MLIC and/or its affiliates (collectively “MetLife”) may conduct investigations in connection with my request to represent Metlife in the solicitation of certain products. I authorize an inquiry to be made of all sources deemed appropriate by Metlife for the purpose of obtaining information concerning my business practices and ethics, background, credit history, and financial status, including, but not limited to, my record, if any, on file with the FINRA Central Records Depository. Any information that MetLife may obtain about me will be treated as confidential and may be shared with the appointing general agent, if necessary. I release the broker/dealer and/or its agents and any person or entity, which provide information pursuant to this authorization, from any and all liabilities, claims or lawsuits in any matter related to the information obtained from any and all of the above referenced sources used. I understand that no right to commission or other compensation shall arise or exist until I have been appointed and all due diligence successfully approved. If I am approved, I shall accept as full compensation for all services to be performed by me, the compensation provided in the applicable commission and compensation schedule as issued, substituted or changed. As an appointed producer, I shall observe and be bound by the rules of MetLife. FAIR CREDIT REPORTING ACT - As part of its regular procedures, MetLife may obtain an investigative consumer report. It may deal with character, reputation, personal traits and life style. It may involve personal interviews with friends, neighbors and associates. I understand I have the right to make, within a reasonable amount of time, a written request for details on the name and address of the agency making the report. I further understand that depending on the state law, subjects of an investigative consumer report may have the right to: 1) request that they be interviewed in connection with the making of the report; and 2) receive a copy of the report, upon request. My signature below constitutes my agreement and authorization to above. I understand that if any of the material information I provided is found to be incorrect or incomplete, MetLife may at its discretion not appoint and/or contract with me or terminate my appointment and/o...
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.
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.
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. You hereby authorize the obtaining of a consumer report and/or investigative consumer report at any time after receipt of this authorization by the Company, and if you are hired, throughout your employment, as permitted by law. You also confirm your understanding and provide consent for this report to be shared with a third-party for whom you may be placed to work as a representative of the Company, if applicable. Signature Today’s Date Full Legal Name (please print) Other or Former Names (please print) Address City/State County Zip Date of Birth** SSN Name on Driver’s License (if different from legal name) Driver’s License # State issued Contact Phone Number E-mail address I would like to receive a copy of my consumer report: ( ) Yes ( ) No
ACKNOWLEDGEMENT AND AUTHORIZATION. You hereby authorize, without reservation, the obtaining of a “consumer report” and/or “investigative consumer report” at any time after receipt of this authorization and during the course of your contract, to the extent permitted by law. You also confirm your understanding and provide consent for this report to be shared with a third-party for whom you may be placed to work as a contractor of The Company, if applicable.
ACKNOWLEDGEMENT AND AUTHORIZATION. This Agreement is hereby deemed to constitute my salary reduction agreement under the 457(b) Deferred Compensation Plan (“Plan”). I agree that salary deferrals under the Plan will not exceed the statutory applicable limit under Section 457(b) of the Internal Revenue Code. I also agree to all of the terms and conditions contained in the Plan, including the conditions that the Plan shall be unfunded and all amounts shall be paid from the general assets of Duke University. Employee Signature Date Duke Benefits Signature Date
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. 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. 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:
