Please check one. The Plan remains consistent with the educational needs of the school and/or district. The Plan was reviewed and amended. Supervisor’s Name (print) Title Signature Second Two Year Review Date The signature below indicates that this educator’s Individual Professional Development Plan was reviewed.
Please check one. The Plan remains consistent with the educational needs of the school and/or district. The Plan was reviewed and amended. Supervisor’s Name (print) Title Signature Initial Review and Approval Date The signature below indicates that 80% of this educator’s Individual Professional Development Plan is not inconsistent with the educational needs of the school and/or district and is designed to enhance the ability of the educator to improve student learning. Supervisor’s Name (print) Title Signature First Two-Year Review Date The signature below indicates that this educator’s Individual Professional Development Plan was reviewed.
Please check one. The Plan remains consistent with the educational needs of the school and/or district. The Plan was reviewed and amended. Supervisor’s Name (print) Title Signature Final Endorsement Date The signature below indicates the supervisor has reviewed this educator’s Record of Professional Development Activities and the reported activities are consistent with the approved professional development plan. Supervisor’s Name (print) Title Signature This document and other Department of Education documents and publications are available on our website at xxx.xxx.xxxx.xxx/xxxxxx. Xxxxxxx Public School Teacher and Caseload Educator Contract Language Table of Contents
Please check one. By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Subscribed and sworn to before me Print Name: Print Title: this day of Notary Public , 20 Tax ID #: APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4
Please check one. Re-Enrollment New Registration How did you hear about our program? Alumni Family Friend/Family Website Facebook Other Student’s Information Last Name First Name Middle Name Name you would like your child to be called: Birth Date / / Sex Primary Home Language Parent/guardian primary home language Child’s Home address City State Zip Family Information List family members and pets your child lives with – include first names, relation and ages of siblings Are both parents at home? If no, which parent is present? General Comments: Parent Information Mother/Guardian Father/Guardian Home Address (include street, city, state, zip) Home Phone Number Cell Phone Number Employer Occupation Business Phone Number Email address (checked often) Best number to reach you at
Please check one. The employee will work at the alternate location days per week for a total of hours. His or her specific work schedule will be: . (This information is required for non-exempt employees and is encouraged for all others.)
Please check one. __________ a. The Plan requires the investment of each beneficiary or participant to be held in a segregated account and the Plan allows each beneficiary or participant to make his own investment decisions and, the decision to purchase the Shares has been made by the beneficiary or the participant and such beneficiary or participant is an Accredited Investor (Please have each such beneficiary or participant execute a separate Questionnaire). OR
Please check one. After my rental, I give the MIA clubhouse manager permission to: Shred deposit check Return deposit check Date must be approved by the clubhouse manager and will be secured only upon receipt of items listed below. Cancellations must be made no later than 30 days prior to event. Please return the following items at least 30 days prior to your event date to Club House Facilities Manager, 0000 Xxxxxxxx Xx, Xxx Xxxx, XX 00000 Completed Forms can be emailed to xxxxxxxxx@xxxxxxxxxxxxx.xxx
Please check one. ☐Yes ☐ No ☐ through an Individual Retirement Account (For U.S. domestic Subscribers only. Does not apply to foreign Subscribers.) ☐ through the Subscriber’s self-directed Xxxxx Plan Account. ☐ through another self-directed employee benefit plan as defined in Title I of ERISA. 1 Any Co-Owner other than a spouse must submit a separate subscription agreement. ANNEX A – FOR INDIVIDUAL SUBSCRIBERS ONLY
Please check one. All of the above dates and times are approved The above dates and times are approved EXCEPT: No Girl Scouts booths can be approved at this location. REASON: Set up booth (Outside): Grocery entrance Home living entrance Both Please specify where you would like troops to set up the Girl Scout cookie booth and any further instructions for them (i.e. will anything be provided, etc.)
