Common use of Please Print Clause in Contracts

Please Print. DATE APPLICANT'S NAME CO-APPLICANT'S NAME CURRENT BILLING ADDRESS: FUTURE BILLING ADDRESS: PHONE NUMBER - Home ( ) - Work ( ) - PROOF OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include name of road, subdivision with lot and block number) PREVIOUS OWNER'S NAME AND ADDRESS (if transferring Membership) ACREAGE HOUSEHOLD SIZE NUMBER IN FAMILY LIVESTOCK & NUMBER SPECIAL SERVICE NEEDS OF APPLICANT The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. | NOTE: FORM MUST BE COMPLETED BY APPLICANT ONLY. A MAP OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the laws of the State of Texas (hereinafter called the Corporation) and (hereinafter called the Applicant and/or Member), Witnesseth: The Corporation shall sell and deliver water water service to the Applicant and the Applicant shall purchase, receive, and/or reserve service from the Corporation in accordance with the bylaws and tariff of the Corporation as amended from time to time by the Board of Directors of the Corporation. Upon compliance with said policies, including payment of a Membership Fee, the Applicant qualifies for Membership as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth therein, a copy of which has been provided as an information packet, for which Member acknowledges receipt hereof by execution of this agreement. A copy of this agreement shall be executed before service may be provided to the Applicant. The Board of Directors shall have the authority to discontinue service and cancel the Membership of any Member not complying with any policy or not paying any utility fees or charges as required by the Corporation's published rates, fees, and conditions of service. At any time service is discontinued, terminated or suspended, the Corporation shall not re-establish service unless it has a current, signed copy of this agreement. If this agreement is completed for the purpose of assigning utility service as a part of a rural domestic water and/or wastewater system loan project contemplated with the Rural Development, an Applicant shall pay an Indication of Interest Fee in lieu of a Membership Fee for the purposes of determining:

Please Print. DATE APPLICANT'S NAME CO-APPLICANT'S NAME CURRENT BILLING ADDRESSAll fields required except e‐mail. Name: FUTURE BILLING ADDRESSBirth Date: PHONE NUMBER - Home Height: Weight : FIRST LAST MM / DD / YYYY FEET | INCHES POUNDS Address: STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY Phone: ( ) - Work ( ) - PROOF E‐Mail: Medical Conditions: Signature: Date: PARTICIPANT’S SIGNATURE TO BE COMPLETED BY THE PARENT OR GUARDIAN IF PARTICIPANT IS UNDER THE AGE OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER 18 ON THE DATE OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include PROGRAM I am the parent or legal, court‐assigned guardian of the minor child whose name appears on this participation agreement. I have acknowledged receipt of roadthe participation agreement, subdivision been given the opportunity to review the participation agreement, read its contents and am satisfied with, and in agreement with, the contents therein, having had the opportunity to discuss the same with lot the Provider and block number) PREVIOUS OWNER'S NAME AND ADDRESS (if transferring Membership) ACREAGE HOUSEHOLD SIZE NUMBER IN FAMILY LIVESTOCK & NUMBER SPECIAL SERVICE NEEDS OF APPLICANT The following information is requested by any third parties of my choosing. I, individually and as parent and/or guardian of my minor child do freely accept the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking terms of the participation agreement. I give my child permission to participate in this programthe programs to be provided by Provider. You are not required My signature below reflects my agreement to furnish this informationfully release the Released Parties, but are encouraged as provided above, from any claim which I may have, and to do sorelease such persons on behalf of my child, for any claim the child may have. This information will not be used in evaluating your application or I further agree to discriminate against you in indemnify the Released Parties for any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. | NOTE: FORM MUST BE COMPLETED BY APPLICANT ONLY. A MAP OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the laws claims of the State child, or of Texas (hereinafter called any member of my or the Corporation) and (hereinafter called child’s family, arising from the Applicant and/or Member), Witnesseth: The Corporation child’s enrollment or participation of the activities of the Provider. I further agree that my child shall sell and deliver water water service be subject to the Applicant mandatory arbitration process described above. These agreements of release and the Applicant shall purchase, receive, and/or reserve service from the Corporation in accordance with the bylaws and tariff indemnity include claims of the Corporation as amended from time to time by the Board negligence of Directors of the Corporation. Upon compliance with said policiesa released party, including payment the negligence of any person or entity for whom a Membership Fee, the Applicant qualifies for Membership as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth therein, a copy of which has been provided as an information packet, for which Member acknowledges receipt hereof by execution of this agreement. A copy of this agreement shall be executed before service released party may be provided to the Applicantvicariously liable. The Board of Directors shall have the authority to discontinue service and cancel the Membership of any Member not complying with any policy or not paying any utility fees or charges as required by the Corporation's published rates, fees, and conditions of service. At any time service is discontinued, terminated or suspended, the Corporation shall not re-establish service unless it has a current, signed copy of this agreement. If this agreement is completed for the purpose of assigning utility service as a part of a rural domestic water and/or wastewater system loan project contemplated with the Rural Development, an Applicant shall pay an Indication of Interest Fee in lieu of a Membership Fee for the purposes of determining:Signature Date PARENT OR GUARDIAN SIGNATURE

Please Print. Service Application and Agreement THIS FORM MUST BE COMPLETED BY APPLICANT ONLY DATE APPLICANT'S APPLICANT or COMPANY NAME OWN First M.I. Last CHECK ONE: RENT CO-APPLICANT'S /SPOUSE NAME CURRENT BILLING SERVICE LOCATION / ADDRESS: FUTURE BILLING ADDRESS: PHONE NUMBER - Home ( ) - Work ( ) - PROOF OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include include name of road, subdivision with lot and block number) PREVIOUS OWNERBILLING ADDRESS: Street Address or PO Box City State Zip PHONE: Home ( ) - E-MAIL ADDRESS: Cell ( ) - CHECK ONE: Work ( ) - PREFERENCE: E - Bill Paper Bill DRIVER'S LICENSE NO. APPLICANT DL # CO-APPLICANT A Copy of D.L. is needed MOVE-IN DATE: METER READING: APPLICANT’S EMPLOYER NAME AND ADDRESS (if transferring Membership) & ADDRESS: Company Name Street Address City/State/Zip ACREAGE HOUSEHOLD SIZE CHECK ONE: SITE-BUILT HOME DOUBLE-WIDE DUPLEX SINGLE-WIDE QUAD PLEX IF RESIDENCE, NUMBER IN FAMILY LIVESTOCK (one meter, one dwelling, standard service) IF BUSINESS, NAME & NUMBER SPECIAL SERVICE NEEDS TYPE OF BUSINESS IF PURCHASING PROPERTY, A COPY OF DEED IS REQUIRED ♦ AN APPLICANT The following MAY PROVIDE A LETTER OF REFERENCE IN LIEU OF PAYING A SECURITY DEPOSIT IF THE LETTER FROM THE IMMEDIATE PAST UTILITY SHOWS NO PENALTIES, LATE PAYMENTS OR DISCONNECTIONS INCURRED IN THE PREVIOUS 12 MONTHS. ♦ REQUEST FOR CONFIDENTIALITY OF PERSONAL INFORMATION I request any personal information is requested held by the Federal Government in order District which is necessary for my water utility account be held as confidential at no charge and not be released to monitor compliance with Federal laws prohibiting discrimination against applicants seeking unauthorized persons. Authority exceptions are stated under House Bill No. 859. Initial: ♦ A partnership between JCSUD and CareFlite allows all customers of the water system to participate in this programbecome members of CareFlite for $1 per month which covers all household members for CareFlite transport services. You are not required to furnish this informationMore details at JCSUD. - Can opt out at any time. OPT OUT of CareFlite Now Initial ♦ IF METER ACTIVATION IS REQUIRED, SPECIFY ONE OF THE FOLLOWING: Unlock meter, but are encouraged to do soleave water OFF in the meter box. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. | NOTE: FORM MUST BE COMPLETED BY APPLICANT ONLY. A MAP OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the laws of the State of Texas (hereinafter called the Corporation) and (hereinafter called the Applicant and/or Member), Witnesseth: The Corporation shall sell and deliver water water service to the Applicant and the Applicant shall purchase, receive, and/or reserve service from the Corporation in accordance with the bylaws and tariff of the Corporation as amended from time to time by the Board of Directors of the Corporation. Upon compliance with said policies, including payment of a Membership Fee, the Applicant qualifies for Membership as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth therein, a copy of which has been provided as an information packet, for which Member acknowledges receipt hereof by execution of this agreement. A copy of this agreement shall be executed before service may be provided to the Applicant. The Board of Directors shall have the authority to discontinue service and cancel the Membership of any Member not complying with any policy or not paying any utility fees or charges as required by the Corporation's published rates, feesUnlock meter, and conditions of serviceleave water ON in the meter box. At any time Applicant authorizes the District to unlock and leave meter in the ON position, even if no one is present at the service location when meter is discontinued, terminated or suspended, the Corporation shall not re-establish service unless it has a current, signed copy of this agreementunlocked. If this agreement is completed for the purpose of assigning utility service as a part of a rural domestic water and/or wastewater system loan project contemplated with the Rural Development, an Applicant shall pay an Indication of Interest Fee in lieu of a Membership Fee for the purposes of determining:.

Please Print. Apply these options to all properties listed below. Option 1(auto-transfer) Option 2 (disconnect notification) Billing Name Address Primary Phone Secondary Phone Service Address(es) of rental property (properties) to be automatically reverted to landlord’s name: PLEASE PRINT I have read and understand the above conditions and hereby authorize Jasper County REMC to make such transfers as described above at the listed location(s) without further notice. SIGNATURE DATE APPLICANT'S NAME COThis form will be in-APPLICANT'S NAME CURRENT BILLING ADDRESSforce after all deposits and fees from the landlord are collected for each property listed above. Member (Tenant) Authorization to Release Information & Third-Party (Landlord) Notification for Disconnection of Service NOTE: FUTURE BILLING ADDRESS: PHONE NUMBER - Home ( IT IS THE LANDLORD’S RESPONSIBILITY TO HAVE THIS FORM COMPLETED AND SUBMITTED TO JASPER COUNTY REMC (REMC) - Work ( IN ORDER TO RECEIVE NOTIFICATION OF DISCONNECTION OF ELECTRIC SERVICE DUE TO NON-PAYMENT TO REMC. This form shall be signed by both the member (tenant) - PROOF OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include name of road, subdivision with lot and block number) PREVIOUS OWNER'S NAME AND ADDRESS (if transferring Membership) ACREAGE HOUSEHOLD SIZE NUMBER IN FAMILY LIVESTOCK & NUMBER SPECIAL SERVICE NEEDS OF APPLICANT The following information is requested by the Federal Government third party (landlord) to be notified in order the event of possible disconnection of service due to monitor compliance with Federal laws prohibiting discrimination against applicants seeking non-payment to participate in this program. You are not required to furnish this information, but are encouraged to do soREMC. This information will rule shall not be used apply where a by-pass or other meter tampering method is discovered on a member’s premises, or in evaluating your application or the case of a member utilizing service in such a manner as to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. | NOTE: FORM MUST BE COMPLETED BY APPLICANT ONLY. A MAP OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the laws make it dangerous for occupants of the State premises. In these cases, an immediate discontinuance of Texas (hereinafter called the Corporation) and (hereinafter called the Applicant and/or Member), Witnesseth: The Corporation shall sell and deliver water water service to the Applicant and premises will be imperative. In the Applicant shall purchaseevent the premises are vacated with or without notice to the REMC or service is disconnected to the premises for any reason, receive, and/or reserve service from Jasper County REMC is not responsible for any damages to the Corporation in accordance with the bylaws and tariff of the Corporation as amended from time to time by the Board of Directors of the Corporation. Upon compliance with said policies, including payment of a Membership Fee, the Applicant qualifies for Membership premises as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for result of failure to deliver electric service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth therein, a copy of which has been provided as an information packet, for which Member acknowledges receipt hereof by execution of this agreement. A copy of this agreement shall be executed before service may be even if notice is provided to the Applicantlandlord. The Board Landlord hereby waives any claim for damages to the premises occurring as a result of Directors shall have the authority failure to discontinue deliver electric service and cancel to the Membership premises. Third-Party (Landlord) Notification Form Name of any Member not complying with any policy or not paying any (Tenant) Service Address City, State, Zip Primary Telephone Number Secondary Telephone Number Third-Party (Landlord) to be notified in the event of possible disconnection of service for non-payment Billing Name Contact Name Telephone Number Street Address City, State, Zip I authorize Jasper County REMC to release information to the designated third party (Landlord). Signature of Member (Tenant) Signature of Third Party (Landlord) Date OFFICE USE ONLY: REMC location number Landlord Consent Agreement Cancellation Please list below the rental properties where you no longer want utility fees or charges as required service to revert back into your name. This form must be submitted by the Corporation's published rates, fees, and conditions of servicelandlord who submitted the Residential Property Landlord Consent Agreement. At any time In the event the premises are vacated with or without notice to the REMC or service is discontinueddisconnected to the premises for any reason, terminated or suspended, Jasper County REMC is not responsible for any damages to the Corporation shall not re-establish service unless it has a current, signed copy of this agreement. If this agreement is completed for the purpose of assigning utility service premises as a part result of failure to deliver electric service even if notice is provided to the landlord. Landlord hereby waives any claim for damages to the premises occurring as a rural domestic water and/or wastewater system loan project contemplated with result of the Rural Developmentfailure to deliver electric service to the premises. Please sign, an Applicant shall pay an Indication date and return the form to: Jasper County REMC XX Xxx 000 Xxxxxxxxxx, XX 00000 PLEASE PRINT ALL INFORMATION Billing Name Contact Name Street Address City, State, Zip Primary Phone Secondary Phone Service Address(es) to be removed from program: Service address must match current REMC records. SIGNATURE DATE The cancellation of Interest Fee in lieu the Residential Property Landlord Consent Agreement becomes effective after the REMC receives and processes this notice of a Membership Fee for the purposes of determining:cancellation.

Please Print. DATE APPLICANT'S NAME CO-APPLICANT'S NAME CURRENT BILLING ADDRESS: FUTURE BILLING ADDRESS: PHONE NUMBER - Home ( ) - Work ( ) - PROOF OF OWNERSHIP PROVIDED BY DRIVER'S LICENSE NUMBER OF APPLICANT LEGAL DESCRIPTION OF PROPERTY (Include If applicable, name of roadorganization or group requesting reservation: Name of Organization/Group: Name of Applicant: Individual authorized to sign this agreement on behalf of the organization/group Address: City: State: Zip Code: Phone Number: Other Number: Provide phone number that may be contacted the day of the event Park Facility Requested: Please note specific areas that would be utilized for the event or provide a sketch of the layout: Date(s) of Requested Reservation: Day(s) of Week Month Date(s) Year Time Requested (includes setup and take down): to Parks open at 6 a.m. and close at 10 p.m. Purpose of this request (i.e. concert, subdivision festival etc.): Approximate number of people expected to attend: Does your organization/group have liability insurance coverage? (check one below) ❒ YES - Please provide copy of proof of insurance ❒ NO Intoxicating alcohol will be dispensed on premises. (check one below) ❒ YES ❒ NO Note section on “Alcoholic Beverage Permit” in attached ordinance/guidelines. A copy of the permit must be on file with lot and block number) PREVIOUS OWNER'S NAME AND ADDRESS (if transferring Membership) ACREAGE HOUSEHOLD SIZE NUMBER IN FAMILY LIVESTOCK & NUMBER SPECIAL SERVICE NEEDS OF APPLICANT The the Recreation Department before the event. Answer the following information is requested by the Federal Government in order to monitor compliance questions with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application a “yes” or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants “no” on the basis of visual observation or surnamelines provided along with a description if stated. | NOTE: FORM MUST BE COMPLETED BY APPLICANT ONLY. A MAP OF SERVICE LOCATION REQUEST MUST BE ATTACHED. White, Not of Black, Not of American Indian or Hispanic Asian or Other Male Hispanic Origin Hispanic Origin Alaskan Native Pacific Islander (Specify) | Female EQUAL OPPORTUNITY PROGRAM Page 1 of 5 AGREEMENT made this day of , , between Mercy Water Supply Corporation, a corporation organized under the laws Will there be any of the State following? A charge of Texas (hereinafter called the Corporation) and (hereinafter called the Applicant and/or Member), Witnesseth: The Corporation shall sell and deliver water water service admission to the Applicant and the Applicant shall purchaseevent? A vendor, receive, and/or reserve service from the Corporation in accordance with the bylaws and tariff registration or entry fee for participants of the Corporation as amended from time to time by the Board of Directors of the Corporation. Upon compliance with said policies, including payment of a Membership Fee, the Applicant qualifies for Membership as a new applicant or continued Membership as a transferee and thereby may hereinafter be called a Member. The Member shall pay the Corporation for service hereunder as determined by the Corporation's tariff and upon the terms and conditions set forth thereinevent? Concessions sold? If yes, a copy of which has been provided as an information packetthe health department permit must be on file with the Recreation Department before the event. Selling of any commodities or articles? If yes, for which Member acknowledges receipt hereof by execution list items being sold: “Kiddie rides” or other amusements? If yes, please describe/list type(s) of this agreementamusements: A Certificate of Liability Insurance must be on file with the Recreation Department before the event. A copy Amplified sound system? Live music? Any tents placed in the park area? If yes, a sketch of this agreement shall tent placement must be executed before service may be provided submitted with application and contact Public Works Dept. at (000) 000-0000 one week prior to the Applicantevent to approve tent placement. Please list any special needs (i.e. bathroom facilities, benches, trash cans): The Board Departments will do their best to provide the requests for your event. Applicant recognizes: That no fires are to be started except in facilities provided for that purpose; that fires must be extinguished; that the facility must be cleaned at the conclusion of Directors shall have its use; that applicants’ use of the authority to discontinue service and cancel facility may not interfere with the Membership use made by others of any Member not complying with any policy or not paying any utility fees or charges as required by the Corporation's published rates, fees, park facilities; that all ordinances and conditions of service. At any time service is discontinued, terminated or suspended, the Corporation shall not re-establish service unless it has a current, signed copy of this agreement. If this agreement is completed for the purpose of assigning utility service as a part of a rural domestic water and/or wastewater system loan project contemplated with the Rural Development, an Applicant shall pay an Indication of Interest Fee in lieu of a Membership Fee for the purposes of determining:permit must be complied with.