Address Telephone Number Sample Clauses
Address Telephone Number. City, State, Zip Code Signature
Address Telephone Number. Legal Xxxx - A legal xxxx is used by residents who cannot sign because of infirmity or illiteracy but not due to legal incompetency. Resident must draw an "X" or other preferred xxxx where the signature should be. The xxxx must be signed and dated by two witnesses who observe Resident make the xxxx. If Resident is physically unable to hold the pen, Facility may ask Resident if he/she consents to the Agreement's terms. If Resident consents to the terms, Facility may execute the xxxx on behalf of Resident. The xxxx must be signed and dated by two witnesses who observe Facility personnel make the xxxx. The xxxx need not be notarized.
Address Telephone Number. I, , agree to take part in the Superior Court Diversion Program (Program) and be monitored by the court. I understand that if I fulfill the terms of this Participant Agreement (Agreement), the Department of Attorney General will not file a charge(s) against me and/or pursue the charges that are currently pending. Furthermore, if I successfully complete the Program, I will be eligible to have my case dismissed and sealed. I understand that if I do not fulfill the terms and conditions of this Agreement, I will be terminated from the Program and my case will proceed through the normal course of felony charging and prosecution. An absolute requirement for this Agreement is that I must avoid committing a crime during the term of my participation in the Program. I understand that if at any time during that period, there is probable cause as determined by the court to believe that I have committed any criminal offense that is not the subject of this Agreement, the court may use its discretion to revoke this Agreement and terminate my participation on the Program. I understand that if, at any time during my participation in the program, it is discovered that I have a criminal record anywhere beyond that included in the discovery materials or previously disclosed by me to the Department of Attorney General, or that I have other pending matters that I knew or should have known about that ultimately result in criminal charges, the court reserves the right to revoke this Agreement. I understand that I am obligated to report any police contact that results in arrest or citation to my case manager as soon as possible. Police contact does not mean the Agreement will be automatically terminated. However, failure to notify my case manager of police contact will be deemed a violation of the Agreement and may result in termination from the Program. I further agree that this Agreement tolls any applicable civil and/or criminal statute of limitations. I understand that it is my responsibility to fulfill any and all conditions of this Agreement. While my case manager will help me fulfill my obligations, it is my responsibility to complete all requirements and provide any documentation that is requested. I understand and agree that my case will be held open until . I also understand that the anticipated length of my participation in the program may be decreased or extended by stipulation of all the parties. I understand that there may be periodic meetings between the court, the ...
Address Telephone Number. I authorize the provider and my pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including the state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine.
Address Telephone Number. (s) Email
Address Telephone Number. Move in Meter Readings * if you are unable to provide a meter reading an estimate will be used) If you previously registered a tenant with us and they have now moved out, you will also need to fill in section 2 of this form. If we do not have the end of tenancy details for a previously registered tenant, we will be unable to register any new tenants. Once the new Tenants details have been received, we will send them out a Welcome Pack confirming that their account has been set up. The fee for registering this tenant will be billed to the Owner as soon as the new Tenants have been registered. Should the fee for this service and any other charges billed to the Owner, not be paid in full, the Tenants will be deregistered. If you have any queries, please get in touch: xxxxxxxxx@xxxxxx0.xx.xx 0333 321 2010
Address Telephone Number. An Officer shall be required to keep on file his/her current home address and telephone number in the department office and the Human Resources Office. The Officer must notify both the department and Human Resources within forty-eight (48) hours of any change, or on the next working day of the Officer, whichever is shorter.
Address Telephone Number. Xxxxxxxxx 00000 Xxxx Xxxxx Xx., Xxxxx 000, Xxx Xxxxx, XX 00000 xxx@xxxxx.xxx (000) 000-0000 Xxxxx X. Xxxxxxxxxx 00000 Xxxx Xxxxx Xx., Xxxxx 000, Xxx Xxxxx, XX 00000 xxx@xxxxx.xxx (000) 000-0000 If you need more space for any response, please attach additional sheets of paper. Please be sure to indicate your name and the number of the item being responded to on each such additional sheet of paper, and to sign each such additional sheet of paper before attaching it to this Investor Questionnaire. Please note that you may be asked to answer additional questions depending on your responses to the above questions. The undersigned recognizes that the Company is relying on the truth and accuracy of such information so that it may rely on certain exemptions from registration contained in the Act and the securities laws of certain states. By signing below, the undersigned consents to the disclosure of the information contained herein and the inclusion of such information in the Registration Statement, any amendments thereto and the related prospectus. The undersigned understands that such information will be relied upon by the Company in connection with the preparation or amendment of the Registration Statement and the related prospectus. THE UNDERSIGNED AGREES TO INFORM THE COMPANY IMMEDIATELY OF ANY CHANGES IN THE FOREGOING INFORMATION.
Address Telephone Number. All parties hereby certifiy that the information contained in this Application, including all assurances and attachments are accurate and correct to the best of our knowledge and belief.