Applicant Certification. The Applicant certifies that it has complied, or that, within 90 days of the date of the grant, it will comply with all applicable requirements of 10 C.F.R. § 1040.5 (a copy will be furnished to the Applicant upon written request to DOE). Designated Responsible Employee Name and Title (Printed or Typed) Telephone Number Signature Date Telephone Number Address Authorized Official: Name and Title (Printed or Typed) Telephone Number Signature Date DOE F 1600.5 OMB Control No. (00-00) 0000-0000 All Other Editions Are Obsolete U.S. DEPARTMENT OF ENERGY Assurance of Compliance Nondiscrimination in State Assisted Programs OMB Burden Disclosure Statement Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of Information Resources Management Policy, Plans, and Oversight, Records Management Division, HR-422-GTN, Paperwork Reduction Project (1910-0400), U.S. Department of Energy, 0000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, XX 00000; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-0400), Xxxxxxxxxx, XX 00000. (Enter name of Borrower’s Subcontractor) (hereinafter called the "Applicant") HEREBY AGREES to comply with Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), Section 16 of the Federal Energy Administration Act of 1974 (Pub. L. 93-275), Section 401 of the Energy Reorganization Act of 1974 (Pub. L. 93-438), Title IX of the Education Amendments of 1972, as amended (Pub. L. 92-318, Pub. L. 93-568, and Pub. L. 94-482), Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112), the Age Discrimination Act of 1975 (Pub. L. 94-135), Title VIII of the Civil Rights Act of 1968 (Pub. L. 90-284), the Department of Energy Organization Act of 1977 (Pub. L. 95-91), the Energy Conservation and Production Act of 1976, as amended, (Pub. L. 94-385) and Title 10, Code of Federal Regulations, Part 1040. In accordance with the above laws and regulations issued pursuant thereto, the Applicant agrees to assure that no person in the United States shall, on the ground of race, color, national origin, sex, age, or disability, be excluded from participat...
Applicant Certification. Per Harbors and Navigation Code 525 (C) “A grant awarded by the department pursuant to subparagraph (A) shall be matched by a 10% contribution from the local agency receiving the grant.” This matching fund may be rendered in cash, or through in-kind contributions which must be verified, and are at the discretion of DBW. These contributions may include (but are not limited to) the following: administrative costs, personnel hours, removal, and/or storage. Xxxxx monies WILL NOT be reimbursed by DBW unless 10% of each reimbursement claim is met.
Applicant Certification. I hereby certify and affirm that the above information, along with any additional forms, supplements, and attachments are true and correct. I understand that providing untrue or false statements in this Application/Agreement may result in the immediate denial or revocation of any authorization to use any Wakulla County Facilities. I further certify and affirm that I have reviewed all of the attached Facility Use Agreement Terms and Conditions, Chapter 23 of the Wakulla County Code of Ordinances and agree to be bound by all such provisions. I understand that the Facility Use Agreement shall not be effective and approved until execution by an authorized representative of Wakulla County. Applicant Name: Signature: Date: Approved by: County Representative: Signature: Date: Title: WAKULLA COUNTY FACILITY USE AGREEMENT TERMS AND CONDITIONS
Applicant Certification. As the duly designated certifying official of the recipient, I also certify that: I am authorized to and do consent to assume the status of responsible federal official under the National Environmental Policy Act of 1969 and each provision of law designated in the 24 CFR 58. Signature of the Certifying Officer of Applicant Date Print Name and Title of Certifying Officer of Applicant Appendix D Appendix E AUTHORIZATION FOR ALTERNATE SIGNATORIES FOR SECTION 106 COMPLIANCE FORMS CDBG Grant Administrators or City Clerks may now sign the Section 106 Compliance Forms including the Exempt from Review Project Determination Form and the Request for Comment on a HUD Project form. In order to take advantage of this opportunity, the Agency Official/CEO must sign this form before a notary public. The CEO is the person who signed the CDBG contract. The grant administrator or City Clerk must also sign this form as a signatory. Note: By signing this agreement, the Agency Official/CEO is still legally responsible for all findings and determinations made on their behalf by the signatory. Once signed, submit this form with your Section 106 compliance documentation. As stated in 36 CFR Part 800, the implementing regulation for Section 106 of the National Historic Preservation Act of 1966, the Agency Official with jurisdiction over an undertaking takes legal and financial responsibility for Section 106 compliance in accordance with Subpart B of 36 CFR Part 800. In the case of the state Community Development Block Grant (CDBG) Program, however, the Agency Official will be the selected non-entitlement cities, which as CDBG recipients are authorized to serve as the Agency Official under 24 CFR Part 58. In the event that the Agency Official is unable to sign the Request for Comment form or the Exempt from Review Project Determination From, however, the following alternates signatories listed below are authorized to act on the behalf of the Agency Official. In the event an alternate signatory is used, the Agency Official remains legally responsible for all required findings and determinations made through the Section 106 process. The signatures attested below are effective as of: (Date) Sincerely, Agency Official (CEO) signature [Name and Title of] Signatory # 1 Signature of Signatory #1 [Name and Title of] Signatory # 2 Signature of Signatory #2 [Name and Title of] Witness Signature of Witness Appendix F
Applicant Certification. The Applicant certifies that it has complied, or that, within 90 days of the date of the grant, it will comply with all applicable requirements of 10 C.F.R. §1040.5 (a copy will be furnished to the Applicant upon written request to DOE). Designated Responsible Employee of Subcontractor Name: Title: Telephone Signature Date: Subcontractor Name: Subcontractor Name: Telephone: Address: Authorized Official of Subcontractor Name: Title: Telephone Signature Date: Instructions for Certification ATTACHMENT C Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transactions
Applicant Certification. I do not have any unanswered questions regarding voluntary exclusion that I believe prevents me from making an informed decision about whether to complete and sign this Application and Agreement. Initial
Applicant Certification. The Employer and the Union are committed to improving the quality of service and professionalism in the parking industry. In order to further this goal, the parties have agreed to establish a basic certification process for applicants. Applicants will be referred to the Local 665 office where they will be introduced to the industry, Union membership and offered a voluntary certification exam (exam). The exam, covering integrity, honesty and basic job skills, will be offered to the applicant by the Union. The exam will be drafted and scored by a third party testing firm on a pass/no pass basis. If the applicant passes the exam, he/she will be considered certified" and awarded a certificate. Employers seeking new hires will view "certified" applicants positively.
Applicant Certification. The form, required by law, in which an applicant certifies that it will adhere to certain statutory requirements, such as the Civil Rights Act of 1964.
Applicant Certification. (Read this certification carefully before you sign and date.) Sign in ink. By signing this application, I certify that all answers are true, complete, and correct to the best of my knowledge. I understand that by giving false information may be grounds for denial of my application. *IF THE ASSISTANCE YOU HAVE APPLIED FOR IS NOT AVAILABLE AT THE TIME OF APPLICATION, YOUR APPLICATION WILL BE PLACED ON A WAITING LIST. THE LTBB HOUSING DEPARTMENT KEEPS A WAITING LIST FOR HOUSING GRANT PROGRAMS THAT REFLECTS TRIBAL PREFERENCE. Applicant’s Signature: Date: LTBB HOUSING USE ONLY Received By: Date: Time: LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS Housing Department 0000 Xxxxx Xxxxxx Xxxxxx Xxxxxxx, XX 00000 NAHASDA RENTAL GRANT AGREEMENT I, , a member of the little Traverse Bay Bands of Odawa Indians, ROLL NO: , hereinafter referred to as “Grantee”, in consideration for being awarded a one time only, short term rental assistance grant from the Little Traverse Bay Bands of Odawa Indians Housing Department NAHASDA account, do hereby agree to the condition on which this grant is made and received. Therefore be it known, I hereby request first months rent and/or security deposit for the premises located at: Street Address City, State Zip As Grantee, I understand that this grant is made subject to all the rules and regulations now or in the future contained in 24 CFR, Part 1000, NAHASDA of 1996, Section 201 (b)(4) that allows for the preference of LTBB Tribal Members or other Native American families. I, , Landlord, hereby agree to rent to: Tenant(s) Name: Beginning the day of , 20 Term of Lease: Utilities Included? 6 months Yes No 1 year (No monthly rentals permitted) Be in agreement that the tenant(s) will pay the landlord(s) an amount of: Security Deposit $ Monthly Rental $ And a like amount on the day of each month. Upon termination of any lease agreement the full amount of the said security deposit (minus any amounts for damages or unpaid rent) will be returned to the LITTLE TRAVERSE BAY BANDS HOUSING DEPARTMENT – NAHASDA accounts. The lease referred to herein is between grantee and landlord(s) and any restitution or damages beyond security deposit paid shall be between named landlord(s) and tenant. ATTENTION LANDLORDS: LTBB DOES NOT SCREEN TENANTS THAT REMAINS THE RESPONSIBILITY OF THE LANDLORD. Grantee: Date: (Signature of Applicant) Landlord(s): Date: (Signature of Landlord) Address of Landlord Telephone Number: The goals and objectives of the Little Trav...
Applicant Certification. The applicant here certifies and affirms (1) that it does not now, nor will it during the performance of any contract arising from this application, unlawfully discriminate against any employee, applicant for employment, client, customer, or other person who might benefit from said contract, by reason of age, race, color, ethnicity, sex, religion, creed, place of birth, or degree of handicap; (2) that it will abide by all relevant local, state and federal laws and regulations; and (3) that it has read and understood the provisions and restrictions in each part above and will comply with all provisions thereof. Signature online / e-signature Date 04/14/2022
