DD YYYY Sample Clauses

DD YYYY. Sex: Male Female (Choose One) Phone: - - Alt Phone Email: Home Address (must be within an AFMA Ambulance Service Area) Facility Name (Optional): Street Address: Mailing Address (If different from above): City: State: Zip Code: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One)) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: ARIZONA FIRE & MEDICAL AUTHORITY ☐ Check/Money Order for $75.00 Made Payable to: Arizona Fire & Medical Authority ☐ Visa ☐ Mastercard Expiration Date / Security Code - - -

DD YYYY. Agreement

DD YYYY. In consideration of the lender's reduction of the interest charged the borrower's account, the United States of America, acting thorough the Farm Service Agency of the United States Department of Agriculture (FSA) pursuant to the Consolidated Farm and Rural Develo.pment Act agrees that in accordance with and subject to the conditions and requirements in this agreement it will reimburse interest to the lender at a maximum of 4 percent per annum of the average daily principal balance, subject to limitations in FSA regulations. The full amount of interest assistance payments made by FSA to the lender will be passed on to the borrower. The initial period of this agreement begins (c) and ends (d)

DD YYYY. The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of $ beginning - - .

DD YYYY. I will meet the responsibilities of a clinical supervisor as outlined in the “Clinical Supervisor Responsibilities” form. This includes meeting one hour face-to-face per week, regardless of hours Student's Name: , has spent with clients. To the degree that I am able, I will try to structure Student's Name: , time so that he/she will have a minimum of 240 hours of face-to-face contact with clients. I understand that this contact can include co-therapy, individual, group, and/or family therapy done by Student's Name: . In addition, I will support Student's Name: , in conducting two taped sessions or provide & document live supervision. I will complete periodic evaluations of Student's Name: , and, after discussing it with him/her, will enter the evaluation into LiveText. I am aware that I will need to have quarterly consultation via phone and/or email with the faculty supervisor. I understand that the faculty member will provide Student's Name: , with group supervision an average of 1.5 hours per week. I, Site Director's Name: agree to give permission to Student's Name: , as the site director of Site's Name: , to Off-Site Supervisor's Name: . Supervisor's Signature: . Date: .

DD YYYY. The CM shall act as a consultant to UC Xxxxx Health, Facilities Design and Construction, to perform Construction Management Services as required and authorized by University pursuant to the Services Scope described in Exhibit M. University will authorize the CM to perform specific services by the issuance of a written Authorization(s) on the form contained in the Exhibits. Each written Authorization will state the specific project and services to be performed, the schedule for their completion, and the method of compensation, which shall be in accordance with Article 5.

DD YYYY. If the debtor fails to pay off the principal debts when the term of the mortgage expires, then:

DD YYYY. During this time, I agree to become familiar with the policies and procedures of the

DD YYYY. The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of $ beginning . MM DD YYYY Date first check mailed . If the date exceeds the 21-Day Rule, check this box And explain under “further matters agreed upon” on reverse. Payment of medical and hospital expenses are subject to the limits of time and amount provided by the Pennsylvania Workers’ Compensation Act and subject to modification or termination with the Act. Compensation payable for weeks days for loss or loss of use of under Section 306(c). Compensation payable for weeks days for healing period for loss or loss of use of under Section 306(c). Compensation payable for weeks days for disfigurement under Section 306(c). Please describe the disfigurement. Further matters agreed upon: We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer. Employee’s signature Date of agreement - - MM DD YYYY Claims Representative’s signature Claims Representative’s name (typed/printed) Telephone

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