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 The signature below indicates that this educator’s Individual Professional Development Plan was reviewed.
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. 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 Tax ID #: 000051 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page 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)
Please check one. Re-Enrollment New Registration How did you hear about our program? Alumni Family Friend/Family Website Facebook Other 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 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: 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 USPS employees and is encouraged for all others.) The employee will work as needed when the following conditions exist: .
Please check one. I did NOT subcontract out ANY portion of our work to another subcontractor. I DID subcontract out our work to:
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
__________ b. The investment decisions made for the Plan are made by a plan fiduciary, whether a bank, an insurance company, or a registered investment advisor. OR
__________ c. The Plan has total assets exceeding $5,000,000.
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.
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.)
Please check one. Commercial - Commercial use includes any use by a business within the Big Bear Service Area, whether for profit or non-profit, whose predominant purpose is to provide goods and/or services to consumers. For purposes of this Resolution, multi-family housing complexes served through a master meter and public entities, including without limitation schools, parks and special districts, are considered commercial users. Commercial users also include hotels, motels, inns, bed and breakfasts or any other transient lodging establishment primarily engaged in providing overnight or otherwise temporary lodging for the general public where meals may be served to transient occupants under applicable laws or regulations.
Please check one. I worked on the Blizzard Bag Day
