PLEASE PRINT OR TYPE Sample Clauses
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PLEASE PRINT OR TYPE. Use a separate registration form for each camper. Favor de escribir con letra de molde y a maquina. ▇▇▇▇▇ una forma por cada participante.
PLEASE PRINT OR TYPE. New Student ( ) Re-Entry Student ( ) Applicant Legal Name: (First) (Middle) (Last) Social Security #: - - Date of Birth: Driver’s License #: Home Telephone: ( ) - Work: ( ) - Cell: ( ) Address: City_ State Zip E-Mail Fax No.
PLEASE PRINT OR TYPE. Property Owner:
PLEASE PRINT OR TYPE. Name of Firm
PLEASE PRINT OR TYPE. Princeton Municipal Utilities Account Number(s) (9 digits)
PLEASE PRINT OR TYPE. NAME OF ORGANIZATION: LIC NO.:
PLEASE PRINT OR TYPE. Complete Section A only if the Agent is contracting with the Company as an individual (in which case, all Agent level compensation will be paid to the Agent as an individual). Complete Section B only if the Agent is a busi- ness entity and this contract is between the Company and such entity (in which case, all Agent level compensation will be paid to the entity unless the Agent completes a separate Agent contract as an individual with the Com- pany). SECTION A SECTION B Individual Agent Name (Print or Type) Signature of Agent Social Security Number Business Entity Name (Print or Type) Signature of Authorized Officer Name of Authorized Officer (Print or Type) Federal Tax Identification Number Name of Managing General Agent (MGA) or General Agent (GA) Signature of SBLI USA Life Insurance Company, Inc. Officer This contract shall take effect on and subsequent con- tract years shall begin with the anniversary of this date. Agent Number