Name Telephone Number. GENERAL INFORMATION Brand name of panel most commonly used by your company: Type of receiver format you prefer: Please indicate the best method for contacting you after business hours. Service Pager Home Mobile Number Leave Message? Yes No Company Name to Use When Dispatching: Phone number to give to your customers: Phone number to transfer your customers to: CONTACT INFORMATION Billing Contact Name: Phone: Email: Data Entry Name: Phone: Email: Activity Reports Name: Phone: Email: Runaway Accounts: Name: Phone: Email: Name: Phone: Email: Name: REPRESENTATIVES Phone: Email: List all owners, officers and employees who will be in contact with the Central Station for any reason pertaining to your company’s accounts. Each representative should have a unique PIN that is 5 numbers in length. Email Addresses are required for NetConnect access. User names will be first initial and last name with the first two letters capitalized. NetConnect login is case sensitive.
Name Telephone Number. FOR THE BUYER: Ian X.X. Xxxxxx (000) 000-0000
Name Telephone Number. My signature indicates that I have read and agree to be bound by the conditions noted on the following six pages of this application/agreement. Signature of Resident Date Signature of Parent/Guardian Date (If applicant is younger than 18 years of age) OFFICE USE ONLY: PLEASE DO NOT WRITE BELOW THIS LINE ID Number Room Assignment 1 Room Assignment 2
Name Telephone Number. 1. Xxxxx X. Xxxxxxxx (000) 000-0000
Name Telephone Number. You consent for me to communicate with you by mail, e-mail, and/or phone at the following addresses and phone numbers, and you will IMMEDIATELY advise me in the event of any change: Street Address E-mail Address Telephone Number (s) Emails, cell phones, computers and faxes are not private: No form of client communication is 100 percent guaranteed to be private. Conversations can be overheard; e-mails can be sent to the wrong recipients and phone conversations can be listened to by others. But in today’s age of e-mail, Facebook, Twitter and other social media, counselors have to be more aware than ever of the ethical pitfalls they can fall into by using these types of communication. Although they add convenience and expedite communication, it is very important to be aware that computers and e-mail and cell phone communication can be accessed relatively easily by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. My computers are equipped with a firewall, virus protection and passwords, and I also password-protect and back up all confidential information from my computers (stored off-site) on a regular basis. If you need to cancel or change an appointment time; a telephone call or SMS (text) may get the message to me in a timely manner. Please notify me if you decide to avoid or limit, in any way, the use of e-mails, cell phones SMS (text), faxes, or storage of confidential information on computers. If you communicate confidential or private information via SMS (text) or e-mail, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and I will honor your desire to communicate on such matters via e-mail. Please do not use e-mail or faxes for emergencies. Due to computer or network problems, e-mails may not be deliverable, and I may not check my e-mails or faxes daily. I prefer to use texting to arrange or modify appointments only. If you e-mail or text me content related to your therapy sessions, please note that e-mail is not completely secure or confidential and unless there is an emergency, therapeutic content is best discussed in-session. Please do not send forwarded messages regardless of how inspirational they may seem to my professional e-mail address...
Name Telephone Number. NOTE TO INTERESTED VENDORS* – Due to security concerns, all offerors must contact the above U.S. Government representative and email the names and company name of all individuals who will represent the company at the pre-proposal conference to xxxxxx-xxx-xxxxxxxxx@xxxxx.xxx . On the date of the pre-proposal conference, company representatives must present matching photo identification in order to be allowed access. Anyone attempting to attend the pre-proposal conference without prior notification will be denied entry.
Name Telephone Number. GENERAL INFORMATION Brand name of panel most commonly used by your company: Type of receiver format you prefer: Please indicate the best method for contacting you after business hours. Service Pager Home Mobile
Name Telephone Number. I consent for my therapist and office manager to communicate with me by mail and phone at the following location, & number, and I will provide timely notification of any changes.
Name Telephone Number. Address ECINS Profile/Case Ref No. (If applicable) Secure Email for response: (Restricted when complete) INFORMATION SHARING AGREEMENT FOR ANTI SOCIAL BEHAVIOUR – Appendix B DERBYSHIRE CONSTABULARY Request for Police Information Subject of Enquiries Address details: House Number/Name Street Town Postcode Tenancy details: ( (include details of whom premises shared with, children, d.o.b.’s etc) Location of Incident Details of Person of Interest: Full Name Date of Birth Gender Brief description of the nature of complaints being investigated: Please advise of any other information which might assist in identifying information relevant to this enquiry [please add continuation sheets as required]: Manager I confirm that I have reviewed this request and that I am satisfied that it is in accordance with the Information Sharing Agreement for Anti-Social Behaviour, to support specific action by this organisation under relevant Anti-Social Behaviour legislation. Name of Manager:
Name Telephone Number. Telephone call-backs may be made to each Issuer and Depositor if joint instructions are required pursuant to this Escrow Agreement. Schedule 3 Escrow Agent Fees: $1,000 - set-up fee payable in advance of the closing of the transaction $3,000 – annual administration fee covering up to 100 deposits, payable in advance of the closing of the transaction and upon each subsequent annual anniversary date. There is an additional administration fee of $750.00 for each block of 50 deposits over the initial 100 deposits. TRANSACTION FEES: Wire transfer of fund: $35.00/domestic wire initiated; $75.00/international payment Checks Cut: $10.00/check cut 1099 Preparation: $12.00/1099 prepared 1042-S Preparation: $50.00/per 1042-S Returned Check: $30.00/returned item An additional annual fee of 15 basis points on the escrow account balance payable in advance may be charged for investments other than institutional money market funds with which the Escrow Agent has established servicing arrangements. Out-of-pocket expenses, fees and disbursements and services of an unanticipated or unexpected nature are not included in the above schedule. EXHIBIT E 2018 STOCK INCENTIVE PLAN TFF PHARMACEUTICALS, INC. 2018 STOCK INCENTIVE PLAN
