Facsimile Number. Date: .....................................................................................
Facsimile Number. 7. Permanent Address: -------------------------- (if different from Address for Notices above)
Facsimile Number. Address to Which Correspondence Should Be Directed (if different from above) x/x Xxxx Xxxxxx Xxxxxxx Xxxx, Xxxxx and Zip Code
Facsimile Number. Peg. BUMN BUMN Employee Mahasiswa Student Lainnya, sebutkan Other, mention it Tahun Kantor Sebelumnya Year Previous Office Tahun Year Kode Pos Post Code Data Keuangan Nasabah/ Customer Financial Data Penghasilan Per Tahun Income per Year Daftar Kekayaan/List of Assets Rumah, Lokasi House, Location Nilai Jual Objek Pajak (NJOP) Selling Value of Tax Object Deposit Bank Bank Deposit Jumlah Amount Lainnya Other aaSn/ Filledpby theeCompacny custiommer only en Khusus diisi untuk nasabah perusah Between IDR 100 – IDR 250 millions Antara Rp 100 - Rp 250 juta Antara Rp 250 –Rp 500 juta Di atas Rp 500 juta Above IDR 500 millions Between IDR 250 – IDR 500 millions Nama Perusahaan Company Name Alamat Perusahaan Company Address Negara Asal Country of Origin No. Telepon
Facsimile Number. (e) Project Name;
Facsimile Number. Email: Accordingly, the undersigned has executed and delivered this Joinder Agreement as of the date written below. Print Name:
Facsimile Number. If Preferred Stock and Warrants are being subscribed for by an entity, the Certificate of Signatory that follows must also be completed. CERTIFICATE OF SIGNATORY To be completed if Preferred Stock and Investor Warrants are being subscribed for by an entity. I, Xxxxxx Xxxxxxx am the President of YCIG, Inc. (the “Entity”). I certify that I am empowered and duly authorized by the Entity to execute and carry out the terms of the Subscription Agreement relating to the sale of Preferred Stock and Investor Warrants of MyDx, Inc. and to purchase and hold the said Securities. The Subscription Agreement has been duly and validly executed on behalf of the Entity and constitutes a legal and binding obligation of the Entity.
Facsimile Number. Social Security Number Email Address: EXHIBIT A TO: WH HOLDINGS (CAYMAN ISLANDS) LTD. The undersigned hereby irrevocably exercises the right to purchase ______________ of the shares of Common Shares, par value $0.001 per share ("Common Shares") of WH Holdings (Cayman Islands) Ltd., a Cayman Islands company (the "Company"), evidenced by the attached Option, and herewith makes payment of the Exercise Price with respect to such shares in full, all in accordance with the conditions and provisions of said Option.
Facsimile Number. Payment by JAC under this Due Process Contract may only be made to Vendor or the Legal Entity to whom Vendor is associated. Vendor designates that payment by JAC under this Due Process Contract shall be made to: XXXX_XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXX Name (Vendor or Legal Entity) Federal Employer Identification Number* * A DFS SUBSTITUTE FORM W-9 FOR THE PAYEE MUST BE ON FILE WITH DFS. STATE OF FLORIDA, JUSTICE ADMINISTRATIVE COMMISSION XXXXXXXXXXXXXXXXX_XX XXXXXXXXXXXXXXXXX Xxxxx X. "Rip" Xxxxxx, Xx. Date Executive Director ADDENDUM A REQUIRED DUE PROCESS VENDOR INFORMATION CHECK ALL THAT APPLY Please check the box next to the description of the service you provide. Court Reporter 1. Court Reporter (Stenographic) 2. Court Reporter (Electronic) 3. Court Reporter – Transcription of Recordings (other than Hearings and Depositions) Videographer Video Conference Services Expert Witness 1. Accounting 2. Accident Reconstructionist 3. Attending/Treating Physician 4. Audio Video Forensics 5. Ballistic/Firearms 6. Biomechanics 7. Blood Splatter 8. Cell Phone/Cellular Tower Mapping 9. Chemist 10. Child Abuse 11. Child Sexual Abuse 12. Crime Scene Reconstruction 13. Computer Forensics 14. DNA Analysis/Testing/Expert 15. Engineering 16. Eyewitness Testimony 17. False Confessions 18. Fingerprint Analysis/Examiner 19. Forensic Pathologist/Medical Examiner 20. Forensic Photography 21. GPS Forensics 22. Handwriting 23. Internet/Social Media 24. Medical Dr./Physician Expert 25. Neurologist 26. Neuropsychologist 27. Nurse Practitioner (RN, LPN) 28. Pediatric Doctor 29. Pharmacologist 30. Physical/Medical Testing (PET Scan, MRI, EEG, QEEG, X-Ray & Brain Imaging) 31. Physician’s Assistant (PA) 32. Polygrapher 33. Psychologist/ Mental Health Expert 34. Radiologist 35. Sanity/Competency Evaluations 36. Sex Offender Evaluation 37. Sexual Predator Commitment Evaluation/Expert 38. Social Worker/Licensed Clinical Social Worker 39. Toxicologist 40. Use of Force 41. Other - Please describe services in box below: Interpreter/Translator 1. Spanish 2. French 3. Haitian/Creole 4. Chinese 5. Other, Specify Sign Language Interpreter Process Server Mitigation Specialist Investigator Copy Service/Printing & Reproduction REVIEW ONLY Cannot exceed 300 characters PLEASE INDICATE WHICH CIRCUITS OR COUNTIES IN WHICH YOU ARE WILLING TO WORK (IN-STATE VENDORS ONLY):
Facsimile Number. (000) 000-0000
