MUST BE COMPLETED. (for Tempus Unlimited, Inc. payroll processing: Client is authorized # of hrs per weekhours per week)
MUST BE COMPLETED. 9. Enter the mailing address if it is different from the legal address in line 8.
MUST BE COMPLETED. (for Tempus Unlimited, Inc. payroll processing: Client is authorized hours per week)
MUST BE COMPLETED. I authorize NCUA to initiate electronic funds transfer payments to the credit union (and from the credit union if Xxx.Xxx option was elected). This authorization replaces all previous authorizations and remains in full force and effect unless NCUA receives a new authorization, 60 days prior to the next established payment date. NAME OF AUTHORIZED REPRESENTATIVE TITLE Please Print Please Print SIGNED DATE PLEASE KEEP A COPY FOR YOUR RECORDS. Please complete and return to: National Credit Union Administration By Fax to: OR By Mail to: 000-000-0000 National Credit Union Administration Office of the Chief Financial Officer 0000 Xxxx Xxxxxx Alexandria, VA 22314-3428 OMB No. 3133-0135 9/30/06
MUST BE COMPLETED. Please print NCUA CHARTER NUMBER (FCU) OR INSURANCE CERTIFICATE (FISCU) CREDIT UNION NAME ADDRESS CITY STATE ZIP EMPLOYER’S ID NO. [TAXPAYER ID NO]. CONTACT PERSON PHONE NO. EMAIL FINANCIAL INSTITUTION NAME 9-DIGIT ROUTING & TRANSIT NO. (RTN) ACCOUNT NO. (Must be at least 4 digits, and only contain numbers, spaces, or dashes) If using a Corporate credit union, please contact them to verify the correct RTN and account numbers for FedACH use.
MUST BE COMPLETED. 1st 2nd 3rd 1st 2nd 3rd
MUST BE COMPLETED. (6) Enter name, telephone number and email of owner, partner or company employee who will be the contact person.
MUST BE COMPLETED. 0xx 0xx 0xx 0xx 0xx 0xx
MUST BE COMPLETED. 1. Has the applicant listed above pled guilty or nolo contendere to or been guilty of a felony or a crime involving moral turpitude since qualifying for this appointment? Yes No (If “Yes”, attach a separate document describing the circumstances related to this question.)
MUST BE COMPLETED. 3. How many PA’s do you currently supervise? List their names: AFFIDAVIT State County being duly sworn according to law, deposes and says that (Supervising Physician’s Name) he/she is the person making the foregoing application; that the statements made therein are true to the best of his/her knowledge and belief; and that he/she has thoroughly reviewed the Rules and Regulations pertaining to Physician Assistants and understands them. (Supervising Physician's Signature) Subscribed and sworn to before me this day of , 20 . (Notary) Commission expires:
