Client Certification. Client acknowledges that it is responsible for the accuracy and completeness of the Information Package and for all other information furnished to StockPlayer and for the accuracy and completeness of the contents of all materials prepared by StockPlayer for and on behalf of Client. The Client hereby designates the individuals listed on Exhibit B attached hereto and incorporated herein by reference as the duly authorized representatives of Client for purposes of certifying to StockPlayer the accuracy of all documents, advertisements or other materials prepared by StockPlayer for and on behalf of Client. The Client agrees to promptly advise StockPlayer in writing of any condition, event, circumstance or act that would constitute a material adverse change in the business, properties, financial condition or business prospects of the Client or which would make any of the information contained in the Information Package or in any report, advertorial or other document prepared by StockPlayer for and on behalf of Client misleading in any material respect. Client hereby agrees that StockPlayer and its directors, officers, agents and employees may rely on the Information Package and on all other information furnished by Client, and on each and every certification provided by an authorized representative of Client, until StockPlayer is advised in writing by an authorized representative of Client that the information previously furnished to StockPlayer is inaccurate or incomplete in any material respect. Client acknowledges that StockPlayer shall have no obligation to provide services hereunder until it has received a written certificate from an authorized representative of Client as follows: StockPlayer shall prepare proofs and/or tapes of the agreed upon materials and information, as set for dissemination, for the Client's review and approval and Client shall sign and return such materials marketing all corrections and changes that the Client believes appropriate. Client acknowledges that StockPlayer will make oral representations based on the information furnished hereunder and the Client authorizes such representations.
Client Certification. Client acknowledges that it is responsible for the accuracy and completeness of the Information Package and for all other information furnished to RAINBOW and for the accuracy and completeness of the contents of all materials prepared by RAINBOW for and on behalf of Client, which are approved by Client. The Client hereby designates the individuals listed on Exhibit B attached hereto and incorporated herein by reference as the duly authorized representatives of Client for purposes of certifying to RAINBOW the accuracy of all documents, advertisements or other materials prepared by RAINBOW for and on behalf of Client. The Client agrees to promptly advise RAINBOW in writing within five (5) business days, of any condition, event, circumstance or act that would constitute a material adverse change in the business, properties, financial condition or business prospects of the Client or which would make any of the information contained in the Information Package or in any report, advertorial or other document prepared by RAINBOW for and on behalf of Client misleading in any material respect. Client hereby agrees that RAINBOW and its directors, officers, agents and employees may rely on the Information Package and on all other information furnished by Client, and on each and every certificate provided by an authorized representative of Client, until RAINBOW is advised in writing by an authorized representative of Client that the information previously furnished to RAINBOW is inaccurate or incomplete in any material respect. Client acknowledges that RAINBOW shall have no obligation to provide services hereunder until it has received a written certificate from an authorized representative of Client as follows: RAINBOW shall prepare proof and/or tapes of all agreed upon materials and information, as set for dissemination, for the Client's review and approval prior to any such dissemination, and Client shall sign and return such materials marking all corrections and changes that the Client believes appropriate. Client acknowledges that RAINBOW will make moral representation based on the information furnished hereunder and the Client authorizes such representations.
Client Certification. Please read and check next to each statement I verify that all information contained herein is correct and true to the best of my knowledge. I also understand that the information provided will be used by Tobii Dynavox for the purpose of obtaining funding and hereby give permission to Tobii Dynavox to release this information as required by the funding sources listed. I understand that I may be able to rent or purchase the equipment that has been prescribed by my physician. The rental duration will be according to the manufacturers’ policy. I understand that if my insurance coverage requires a capped rental, I will be subject to the Terms and Conditions of the Capped Rental program. Signature(s) of person(s) completing this form:
1. Name & Relationship to Client (Please Print)
2. Name & Relationship to Client (Please Print)
Client Certification. Please read and check next to each statement Signature(s) of person(s) completing this form:
1. Name & Relationship to Client (Please Print)
Client Certification. You as the recipient will print your name and case number and date in this section. You will certify that your service provider is qualified to provide personal care services for you as authorized by the county. You, your authorized representative or the person authorized to make medical decisions for you must sign and date the form. Please send the completed form to the county IHSS office within 5 calendar days. If you have any questions, please contact your social worker at the county IHSS office. • This form is to be completed in triplicate. • This form must be completed prior to enrollment for each service provider/client relationship. Part 1 is to be completed by the service provider. • Part 11 is to be completed by the client or authorized representative as long as the authorized representative is • Part III is to be completed by the county. • The original form is to be maintained by the county and a copy given to the provider and the recipient.
PART I SERVICE PROVIDER SERVICE PROVIDER NAME SOCIAL SECURITY NUMBER ADDRESS (Street, City, Zip) PHONE ( ) • I certify that all claims, which I submit, for services to clients of the Personal Care Services Program will be provided as authorized for the client. • I certify that all information submitted to the county will be accurate and complete to the best of my knowledge. • I understand that payment of these claims will be from federal and/or state funds and that any false statement, claim, or concealment of information may be prosecuted under federal and/or state laws. • I agree that services will be offered and provided without discrimination based on race, religion, color, national or ethnic origin, sex, age, or physical or mental disability. SERVICE PROVIDERS SIGNATURE DATE
Client Certification. I certify that the service provider named above is qualified to provide personal care services for me as authorized by the county. CLIENT’S NAME CASE NUMBER CLIENT’S SIGNATURE (Or Authorized Representative) DATE
Client Certification. Client acknowledges that it is responsible for the accuracy and completeness of the Information Package and for all other information furnished to NHOB and for the accuracy and completeness of the contents of all materials prepared by NHOB for and on behalf of Client, provided that such latter materials have received Client's prior written approval. The Client hereby designates the individuals listed on Exhibit B to this Agreement as the duly authorized representatives of Client for purposes of certifying to NHOB the accuracy of all documents, advertisements or other materials prepared by NHOB for and on behalf of Client. The Client agrees to promptly advise NHOB in writing of any condition, event, circumstance or act that would constitute a material adverse change in the business, properties, financial condition or business prospects of the Client or which would make any of the information contained in the Information Package or in any document prepared by NHOB for and on behalf of Client misleading in any material respect.
Client Certification. Client acknowledges that it is responsible for the accuracy and completeness of the Information Package and for all other information furnished to Sinclair-Davis. Client agrees to promptly advise Xxnclair-Davis in writing of any condition, event, xxrcumstance or act that would constitute a material adverse change in the business, properties, financial condition or business prospects of Client or which would make any of the information contained in the Information Package or in any report or other document prepared by Sinclair-Davis for and on behalf of Client misleadxxx xx xxx xxxerial respect. Client agrees that Sinclair-Davis and its directors, officers, agents xxx xxxxxxxxx may rely on the Information Package and on all other written information furnished by Client, and on each and every certification provided by an authorized senior executive officer of Client, until Sinclair-Davis is advised in writing by an authorizxx xxxxxx xxxcutive officer of Client that the information previously furnished to Sinclair-Davis is inaccurate or incomplete in any xxxxxxxx xxxxect.
Client Certification. Client acknowledges that it is responsible for the accuracy and completeness of the Information Package and for all other information furnished to NHOB and for the accuracy and completeness of the contents of all materials prepared by NTHOB for and on behalf of Client. The Client hereby designates the individuals listed on Exhibit B to this Agreement as the duly authorized representatives of Client for purposes of certifying to NEOB the accuracy of all documents, advertisements or other materials prepared by NHOB for and on behalf of Client. The Client agrees to promptly advise NEOB in WRITING of any condition, event, circumstance or act that would constitute a material adverse change in the business, properties, financial condition or business prospects of the Client or which would make any of the information contained in the Information Package or in any document prepared by NHOB for and on behalf of Client misleading in any material respect.
Client Certification. Client acknowledges that it is responsible for the accuracy and completeness of the Information Package and for all other information furnished to Sxxxxxxx Xxxxx Trading Corp. The Client agrees to promptly advise Sxxxxxxx Xxxxx Trading Corp. in writing of any condition, event, circumstance or act that would constitute a material adverse change in the business, properties, financial condition or business prospects of the Client or which would make any of the information contained in the Information Package or in any report or other document prepared by the Sxxxxxxx Xxxxx Trading Corp. for and on behalf of Client misleading in any material respect. Client hereby agrees that Sxxxxxxx Xxxxx Trading Corp. and its directors, officers, agents and employees may rely on the Information Package and on all other information furnished by representative of Client, until Sxxxxxxx Xxxxx Trading Corp. is advised in writing by an authorized representative of Client that the information previously furnished to Sxxxxxxx Xxxxx Trading Corp. in inaccurate or incomplete in any material respect.
