CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment.
CERTIFICATION AND SIGNATURE. I permit the DU Office of Financial Aid to reduce or increase my student budget, thus changing my financial aid eligibility. I understand that I am responsible for ensuring that this form is complete prior to being submitted to the DU Office of Financial Aid. I understand that financial aid funds cannot be disbursed to me prior to the scheduled disbursement date for the term(s) I will be participating in the consortium program.
CERTIFICATION AND SIGNATURE. Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. -------------------------------------------------------------------------------- a. TYPED NAME OF CERTIFYING b. TITLE c. TELEPHONE (Include Area OFFICIAL Chief, Civil Air Code) XXXXX X. XXXXXX, COL Division (000)000-0000 USAF Directorate of Operations -------------------------------------------------------------------------------- d. ADDRESS (Include Zip Code) 17. REQUIRED DISTRIBUTION HQ AMC/DOF [X] a. CONTRACTOR 000 XXXXX XX., XXXX 0X0 [ ] b. SUBCONTRACTOR XXXXX XXX, XX 00000-0000 [X] c. COGNIZANT SECURITY OFFICE FOR ----------------------------------------- PRIME AND SUBCONTRACTOR e. SIGNATURE [ ] d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY ADMINISTRATION [X] e. ADMINISTRATIVE CONTRACTING /s/ Xxxxx X. Xxxxxx OFFICER [X] f. OTHERS AS NECESSARY Xxxxxx Xxxxxxxx 30 Jun 03 NQ AMC/SFI -------------------------------------------------------------------------------- DD FORM 254 (BACK), DEC 1999 SOLICITATION NO.: F11626-03-R-0002 CONTRACT NO.: F11626-03-D-0024
CERTIFICATION AND SIGNATURE. I understand that I will be held as legally bound, obligated, and responsible by the use of my electronic signature as I would be by a handwritten signature and that legal action can be taken against me based on my use of the electronic signature in submitting electronic documents. Signature Date
CERTIFICATION AND SIGNATURE. Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below.
CERTIFICATION AND SIGNATURE. By signing this Agreement, I make the following certifications:
CERTIFICATION AND SIGNATURE. Security requirements started herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below.
a. TYPED NAME OF CERTIFYING OFFICIAL b. TITLE c. TELEPHONE (Include Area Code) XXXXX X. XXXXXX SECURITY’S CONTRACTING OFFICER’S (000) 000-0000 XXXXX, XXXXXX@XXXX.XXX REPRESENTATIVE (COR)
CERTIFICATION AND SIGNATURE. By my signature below, I understand, agree and/or confirm that:
1. Any dependents I am enrolling meet the eligibility requirements described above.
2. I have furnished satisfactory evidence of such dependency to the Benefits Specialist.
3. By my signature on this application, I certify that I understand and agree that to claim coverage for an ineligible dependent is serious misconduct, and in the event of such misconduct, I agree to reimburse the CLIU for any costs incurred, and may be subject to disciplinary action.
CERTIFICATION AND SIGNATURE. By signing this Agreement, the undersigned authorized representative of the Employer hereby authorizes the Employer's bank to debit the bank account identified above and authorizes Pension Fund to accept these deposits. These debits and deposits are to be made under the Rules of the Automated Clearing House (ACH). The undersigned authorized representative of the Employer further makes the following certifications:
CERTIFICATION AND SIGNATURE. I certify that I will use the stipend requested toward the business use designated above. I further certify that I have read, understood and intend to comply with University-issued Cell Phones and Wireless Communication Stipend Policy.
