PLEASE CHECK THE APPROPRIATE BOX. I certify, pursuant to Public Law 2012, c. 25, that neither the bidder listed below nor any of the bidder's parents, subsidiaries, or affiliates is listed on the N.J. Department of the Treasury's list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed below, or I am an officer or representative of the entity listed below and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below. OR I am unable to certify as above because the bidder and/or one or more of its parents, subsidiaries, or affiliates is listed on the Department's Chapter 25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below and sign and complete the certification below. Failure to provide such will result in the proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law.
PLEASE CHECK THE APPROPRIATE BOX. [ ] (a) The undersigned meets the definition of an “Accredited Investor.” [ ] (b) The undersigned does not meet the definition of an “Accredited Investor.”
PLEASE CHECK THE APPROPRIATE BOX. [ ] (a) The undersigned meets the definition of an “Accredited Investor.” [ ] (b) The undersigned does not meet the definition of an “Accredited Investor.” 2 Since the July 21, 2010 enactment of Section 413(a) of the Xxxx-Xxxxx Xxxx Street Reform and Consumer Protection Act, the value of a person’s primary residence must be excluded from his/her net worth. On December 21, 2011, the SEC adopted amendments to Rule 501(a)(5) and Rule 215 to clarify treatment of indebtedness secured by a person’s primary residence when calculating his or her net worth (Release No. 33-9287 Net Worth Standard for Accredited Investors). These amendments are effective February 27, 2012. It is important to follow carefully the instructions set forth in this Questionnaire when calculating net worth.
PLEASE CHECK THE APPROPRIATE BOX. 4. The donor has read and agrees to be bound by the Rules of Conduct regarding Donations set forth in Mayor’s Memorandum 2012-3, dated May 16, 2012.
PLEASE CHECK THE APPROPRIATE BOX. Are you the Owner # Property Manager # Action Requested: Add Direct Deposit # Change Bank or Acct. # # Cancel Account # Bank Name: Transit (ABA) #: Account # This is a: Checking Account # Savings Account # I hereby authorize Idaho Housing and Finance Association to initiate deposits to my account(s) as indicated above and the depository named above, to credit the same to such account.
PLEASE CHECK THE APPROPRIATE BOX. [ ] (a) The undersigned Shareholder meets the definition of an “Accredited Investor.” [ ] (b) The undersigned Shareholder does not meet the definition of an “Accredited Investor.” If you checked the box next to (b) above, please turn to Section C and complete the Purchaser Representative Agreement. The undersigned hereby represents and warrants to Acquiror that (i) the information contained herein is complete and accurate and may be relied upon by Acquiror, (ii) the undersigned, together with his or her investment advisors, has such knowledge and experience in financial matters that he, she or they are capable of evaluating the merits and risks of the investment, and (iii) the undersigned will notify Acquiror or its counsel immediately of any material change in such information occurring prior to the acceptance or rejection of his or her shares of Acquiror common stock to be received in the Merger. The undersigned has or have executed this Shareholder Questionnaire this day of , 2003. Print Name of Shareholder Signature of Shareholder Print name of Spouse (if APT Shares are held in joint name or are community property) (if APT Shares are held in joint name or are community property) Signature of Spouse
PLEASE CHECK THE APPROPRIATE BOX. [ ] (a) The undersigned meets the definition of an “Accredited Investor.” [ ] (b) The undersigned does not meet the definition of an “Accredited Investor.” The undersigned hereby represents and warrants to the Company that (i) the information contained herein is complete and accurate and may be relied upon by the Company, (ii) the undersigned, together with his or her investment advisors, has such knowledge and experience in financial matters that he, she or they are capable of evaluating the merits and risks of the investment, and (iii) the undersigned will notify the Company or its counsel immediately of any material change in such information occurring prior to the acceptance or rejection of his or her stock in the Company. The undersigned has or have executed this Investor Questionnaire on this ___ day of ___________, 2017. Print Name of Stockholder Signature of Stockholder Print name of Spouse Signature of Spouse (if the Shares are held in joint name or are (if the Shares are held in joint name or are community property) community property)
PLEASE CHECK THE APPROPRIATE BOX. [ ] The research to be conducted under this CRADA does not involve animal subjects within the meaning of 7 U.S.C. 2131 et seq. and 9 CFR Parts 1, 2, and 3. [x] The research to be conducted under this CRADA involves animal subjects within the meaning of 7 USC 2131 et seq. and 9 CFR Parts 1, 2, and 3, and Collaborator agrees to take all steps required by NOAA to assure compliance with 9 CFR Parts 1, 2, and 3. Collaborator certifies that research involving animal subjects shall not begin until documentation of the appropriate reviews and certifications have been provided to and approved by NOAA.
PLEASE CHECK THE APPROPRIATE BOX. [x] Laboratory/Program does not have an existing contractual or similar legal relationship with the prospective partner(s); or [ ] Laboratory/Program does have an existing contractual or similar legal relationship with the prospective partner(s), but the Laboratory Director has determined, in accordance with the factors listed at 15 CFR 17.3(c), that the technical subject matter of the funding agreement is sufficiently distinct from that of this CRADA; Please reference any existing contracts or other agreements below: Type of Relationship Tracking Number Start Date End Date
