Address City State Zip. 0000 Xxxxx Xxxxxxx Xxxxxxx Texas 77036 0000 Xxxxx 00xx Xxxxxx XxXxxxx Xxxxx 00000 0000 Xxxx Xxxx Xxxx. #0000 & #0000 Xxxxxxxx Xxxxx 00000 0000 Xxx Xxxxxxx Xxxx Xxxxxx Xxxxx 00000 000 Xxxxxxxx Xxxxx Lafayette Louisiana 70506 Schedule 7.3 to Amended and Restated Loan and Security Agreement Real Estate 1 SCHEDULE 8.5 to Amended and Restated Loan and Security Agreement DEPOSIT ACCOUNTS Conn Appliances, Inc. Depository Bank Type of Account BANK OF AMERICA Store Deposit Account BANK OF AMERICA Letter of Credit Deposit Account BANK OF AMERICA LC Disbursement Account CAPITALONE Controlled Disbursement Account CAPITALONE General Operating Account CAPITALONE Payroll Account CAPITALONE Payment Center Account CAPITALONE Credit Card Settlement Account CAPITALONE Louisiana Store Depository Account COMMUNITY BANK OF TEXAS Store Deposit Account JPMORGAN CHASE Depository Account JPMORGAN CHASE General Operating Account SUNTRUST General Corporate Account BBVA COMPASS BANK Store Deposit Account XXXXX FARGO BANK Store Deposit Account WOODFOREST Store Deposit Account Conn Credit Corporation, Inc. NONE. Conn Credit I, LP NONE. Schedule 8.5 to Amended and Restated Loan and Security Agreement Deposit Accounts 1 SCHEDULE 8.6.1 to Amended and Restated Loan and Security Agreement CREDIT CARD AGREEMENTS
Address City State Zip. Home Phone Cell Phone Preferred email 1 Family Member Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method * (See Appendix C for Card Details) Yearly (Credit/Debit Card) Monthly (Credit/Debit Card) Monthly (Credit/Debit Card) *All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in Siskiyou Vital Medicine LLC Medical Agreement Form. I further certify that I have received a copy of this form. Date & Time (mm/dd/yyyy hhmm) Signature Fee Itemization Services for services provided by Siskiyou Vital Medicine: Family Plan $220* per month Includes 2 adults plus 1 youth (Additional $30 per youth (Birth to 17)) Individual Plan $100* per month (Includes 1 adult) Youth $ 50* per month Includes on 1 youth (Birth to 17) (one adult membership required) Personalized Plan. Includes # adult(s). # youth(s) *Plans paid by employers may be at a rate other than as published above. Payment Method: Full Name on Card Credit Card #
Address City State Zip. Phone E-mail Fax Official California Fishing Passport Program Educational Partners agree to abide by the following guidelines, requirements and ethical fishing standards: • Provide California Fishing Passports free of charge to anglers who possess a valid annual California fishing license, and to children under the age of 16, upon request • Provide California Finfish and Shellfish Identification Books free of charge (at your discretion). No money/compensation may be collected for the books. • Prior to stamping Fishing Passports, confirm each fish species or witness signature • Educate fellow anglers about the California Fishing Passport program • Educate fellow anglers regarding ethical fishing practices and standards With this approved and signed document, the California Department of Fish and Game (DFG) agrees to provide official Educational Partners the opportunity to obtain the following items:
Address City State Zip. Check One: Facility Use_____ Massage Use_____ Facility & Massage Use_______ Climbing Wall_____ ADDITIONAL HOUSEHOLD MEMBERS) NAME (FIRST, MI, LAST) BIRTHDATE □ MALE □ FEMALE NAME (FIRST, MI, LAST) BIRTHDATE □ MALE □ FEMALE NAME (FIRST, MI, LAST) BIRTHDATE □ MALE □ FEMALE NAME (FIRST, MI, LAST) BIRTHDATE □ MALE □ FEMALE EMERGENCY CONTACT INFORMATION- Required and must be filled out by applicant. NAME (FIRST, MI, LAST)
