Additional Information Required. If additional information is required, a Service representative will generally contact the Plan Sponsor or the Plan Sponsor's representative and explain what is needed to complete the submission. The Plan Sponsor will have 21 calendar days from the date of this contact to provide the requested information. If the information is not received within 21 days, the matter will be closed, the compliance fee will not be returned, and the case may be referred to Employee Plans Examinations. Any request for an extension of the 21-day time period must be made in writing within the 21-day time period and must be approved by the Service (by the applicable group manager).
Additional Information Required. OWNERSHIP (%): Male Female RACE: (Voluntary) American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White ETHNICITY (Voluntary) Hispanic or Latino VETERAN STATUS: Veteran Non-Veteran Primary Business Activity: NAICS Annual Sales in Last Fiscal Year: Year Business Established: Total Full Time Employees (2 half time employees equals 1 full time employee): Estimated Jobs Created by this Loan over next 3 years: Estimated Jobs Retained by this Loan over next 3 years: Does the Borrower, including any parent or subsidiary or affiliated entity, in Virginia: have 250 or fewer employees? Yes No Current # OR have less than $10,000,000 in annual gross revenues over each of the last three (3) fiscal years? Yes No OR have less than $2,000,000 in net worth? Yes No If the answer to any of the following questions is “yes”, please furnish details on an attached sheet. Have any owners, officers, directors, guarantors, general partners, stockholders or limited partners owning 20% or more of the Borrower ever been charged with, or convicted of, any criminal offense, other than minor motor vehicle violations? Yes No Has the Borrower or management of the Borrower been informed of any current or on-going investigation of the Borrower with respect to possible violations of state or federal securities laws? Yes No Has the Borrower or any owners, officers, directors, guarantors, general partners, stockholders of limited partners owning 20% or more of the Borrower been in receivership or adjudicated as bankrupt? Yes No Is the Borrower or any of its owners, officers, directors, guarantors, general partners, stockholders or limited partners owning 20% or more of the Borrower involved in any pending lawsuits? Yes No Does the Borrower or any guarantors owe past due federal, state or local taxes of any nature? Yes No
Additional Information Required. 1. Does the student require any special accommodations to participate in the classroom phase (i.e., test being read to him/her, an interpreter, seating arrangements, etc.)? Yes No If Yes, please explain:
Additional Information Required. Family Doctor: Telephone: Does the student require any special accommodations to participate in the behind-the-wheel portion of the course? Y / N If yes, please explain Is the student currently taking medication that would affect their ability to operate a vehicle safely? Y / N If yes, please explain Does the student have any medical conditions that would pose a concern with the behind-the-wheel instruction? Y / N If yes, please explain In the last 6 months, has the student suffered from a fainting spell, blackout, seizure, uncontrolled loss of consciousness, or has a physical or mental condition that may affect their ability to operate a motor vehicle safely? Y / N If yes, a letter must be provided from the student’s physician indicating that the condition has been corrected and/or is under control and meets the physical and mental requirements to operate a motor vehicle safely. Has the student ever taken Driver’s Education before? Y / N Has the student ever had a license suspended or revoked? Y / N Does student wear corrective lenses? Y / N By signing below you are agreeing to/verifying that the student’s visual acuity is 20/40 corrected or better to obtain an unrestricted license. By signing this disclaimer, I hereby agree that my child is mentally and physically able to complete the required behind-the-wheel training with a licensed driving instructor and does not have a mental and/or physical disability and is not taking any medication that may cause endangerment or compromise the well –being of the driving instructor or passenger. I understand that if my student does have a disability or is on medication that may endanger the well – being of the driving instructor or passenger, and I, the parent or guardian, do not disclose this information to ASDE, said company has a right to discontinue driver education for my student at any given time. I also understand that any damages caused by said student that may occur during drive times resulting in not disclosing any student disabilities and/or medications become my responsibility as a parent/guardian. PARENT SIGNTURE X DATE / / RELEASE, ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT All Star Driver Education, Inc. (ASDE) I make this release, assumption of risk and indemnification agreement as parent and natural guardian or legal guardian of (Children). In consideration of the Children’s participation in the driving instruction and/or road testing and any and all events or activities in relation thereto (...
Additional Information Required. If required in the bid specifications,Contractor shall complete items I and/or II below: Statement of past three (3) years experience on public construction projects. Public Body/ Reference Name/ Original Price/ Project Name/Year Phone# Final price Subcontractors List any determinations by a court or governmental agency for violations of federal, state or local laws, including but not limited to violations of contracting or antitrust laws, tax or licensing laws, environmental laws, the Occupational Safety and Health Act (OSHA), the National Labor Relations Act (NLRA), or federal Xxxxx-Xxxxx and related Acts. Date N/A Law Determination Penalty Certificate No: ECC93439-18 Xxxx X Xxxxxxxxx, Mayor Certificate of Registration issued by the Department of Buildings of the City of Chicago This is to Certify that located at H & H ELECTRIC CO. - ECC93439 0000 XXXXXXXX XX. XXXXXXXX XXXX, XX 00000 having complied with the requirements of Ordinances passed by the City Council of the City of Chicago providing for the registration of electrical contractors is hereby recorded as a REGISTERED ELECTRICAL CONTRACTOR General Electrician and is entitled to perform electrical work in the City of Chicago under the Direction of Supervising Electrician provided that such work permits are subject to the provisions of all the Ordinances of the City of Chicago now in force or which may be hereafter passed. This certificateEXPIRES December 29, 2022. SUPERVISING ELECTRICIAN: XXXXX X XXXXXXXXX - SE6318 In Witness Whereof I have hereunto set my hand on October 4, 2021. File Number 0000-000-0 To all to whom these Presents Shall Come, Greeting:
Additional Information Required. Supporting documentation (e.g. invoice(s), GL reports, timekeeping records, etc.) must be recorded on Detail worksheet. Upon completion, print Disbursement Request and Detail to PDF, sign electronically, and attach copies of supporting documentation. Submit to XXXXxxxxxxxx@xx.xxxxxx.or.us for review and processing of disbursement. Questions about this form can also be directed to XXXXxxxxxxxx@xx.xxxxxx.or.us. Xxxxxx County Disbursement Request Detail Recipient: 0 Date: 1/0/1900 Project Name: 0 Project Number: 0 Funding Program: 0 Date Description Personnel Services Materials & Services Equip or Capital Purchases Administrative Total ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ insert extra lines if needed ‐ Total Disbursement Request ‐ ‐ ‐ ‐ ‐ Annual Equitable Outcomes and Community Engagement Report Recipient Name: Contact Name: Contact Phone: Grant #: Date Submitted: Promoting Equitable Outcomes The U.S. Treasury encourages uses of funds that promote strong, equitable growth, including racial equity. Describe efforts to promote equitable outcomes, including how programs were designed with equity in mind. Using the four points below: describe how your project will consider and measure equity at the various stages of your project, describe how your project’s use of funds prioritizes economic and racial equity as a goal, describe how you identified specific targets intended to produce meaningful equity results at scale and explain the strategies to achieve those targets. The information provided in this section will be used in DAS’ annual Recovery Plan Performance Report as required in the Compliance and Reporting Guidance in section C.3. Goals Are there particular historically underserved, marginalized, or adversely affected groups that you intend to serve within your jurisdiction? Response:
Additional Information Required. Applicant shall complete the official LEDC Building Improvement Loan/Grant application, sign and approve the loan/grant agreement, submit a $50 application fee and submit the following required documents with the application:
Additional Information Required. If Merchant’s business is NOT incorporated, please submit the following TWO items:
Additional Information Required. The Participant must provide the following additional information to the Administrator demonstrating that no portion of the rollover contribution contains after-tax contributions or earnings:
Additional Information Required. If Xxxxxxxx’s business is NOT incorporated, please submit the following TWO items: 🞏 a copy of sole proprietor’s valid government ID (i.e., driver’s license or passport) �� Business account void cheque If Merchant’s business is incorporated, please submit the following THREE items: 🞏 Business account void cheque 🞏 a copy of the Certificate of Incorporation 🞏 a copy of the authorized signing officer’s valid government ID (i.e., driver’s license or passport) Payment Platforms and Fee Schedule: Payment Platform Alipay WeChat Pay Union Pay Offline Transaction Charge Rate 🞏 % 🞏 % 🞏 % Online Transaction Charge Rate 🞏 % 🞏 % 🞏 % Settlement Currency (Choose one currency for each Payment Platform) 🞏USD 🞏CAD 🞏USD 🞏CAD 🞏USD 🞏CAD Hardware: Type Quantity Amount (per Terminal) Total Amount Leased Terminal(s) Monthly fee of $15.95 CAD (plus HST) Total monthly fee of $ CAD (plus HST) Purchased Terminal(s) Purchase price of $310.00 CAD (plus HST) Total purchase price of $ CAD (plus HST)
