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. 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. Agreement
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 40 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: . I will complete periodic evaluations of Student's Name: and, after discussing it with the student, I will provide the student with the original to submit into Blackboard. I am aware that I will speak with the faculty supervisor at least once per term.
DD YYYY. Xxxxxx, after concurrence by United States Department of Agriculture, has agreed to write-down a portion of the borrower's debt. The debt prior to the write-down is:
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. Note: Enter the estimated completion (End) date for support under this agreement.
DD YYYY. During this time, I agree to become familiar with the policies and procedures of the
DD YYYY. Within the period of issuance and the loan limit as agreed above, the specific amount of each loan shall be subject to the actual amount received by Party A, and the borrower has no objection to this provision.
DD YYYY. The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of $ beginning - - .
