PLEASE READ AND SIGN. You request that Pershing Advisor Solutions open a brokerage account(s) in the names listed as account holders on this Agreement. You authorize Pershing Advisor Solutions to open additional brokerage accounts with the same registration using the address of record and other information that you provide in accordance with instructions received from your Authorized Advisor(s). You acknowledge that this Agreement (including the account Registration and the Terms and Conditions of the Agreement incorporated by reference into this Agreement as a material part thereof) governs each account opened under this Agreement (including any accounts opened as instructed by your Authorized Advisor[s]).
PLEASE READ AND SIGN. For the comfort of your pet, bedding can be used for your pet's boarding stay. Please understand that pets sometimes behave differently while boarding than at home. If you have provided bedding or would like the boarding team to use their bedding, you assume all risks. This includes any lost, ripped, or chewed bedding. By signing below you also acknowledge that if your pet were to chew and ingest some or part of bedding causing your pet to become sick, or require a life threatening intestinal surgery to remove the bedding, you assume all risks and financial responsibility as well.
PLEASE READ AND SIGN. I have read, understood, and accepted the conditions of the WAIVER AND RELEASE OF LIABILITY printed above. Contractor’s Signature Print Name Date
PLEASE READ AND SIGN. You hereby request that Your Broker maintain a Brokerage Account in the name(s) listed on this Application. You acknowledge that you have received, read and understood the SWST Cash Account Agreement Section of the Customer Information Brochure and you agree to be bound by the terms and conditions of the Agreement that apply to your Brokerage Account, as amended and that you will contact Your Broker regarding any questions that may relate to your account.
PLEASE READ AND SIGN. I understand that Acelleron Medical Products or its assignee (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic. • Provider provides at least a three-year manufacturer’s compressor warranty on all its nebulizers. • I certify that the information provided by me and applying for payment under Title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct. • I understand that I am personally responsible to Provider for charges not paid in full by insurance coverage, deductible or co-pay responsibilities up to the maximum amount of $195. • I authorize release of all medical records in relation to the above referenced equipment. • I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits. • I agree that Provider may contact me in the future, via telephone, text, email or regular mail. • I have received the equipment in good working order and been instructed on the proper and safe use of all the above listed equipment. • I certify that I have read the terms and conditions of this agreement (front and back) as well as, any attachments, and agree to their content. • I certify that I have been provided the Hours of Availability, Community Resources, Instructions for Set-Up of HME, Safety Precautions, Emergency or Natural Disaster Information, Customer Complaint Policy, Customer Xxxx of Rights & Responsibilities, HIPAA Privacy Notice and DME Supplier Standards (view back of page). • Entiendo que los productos médicos Acelleron o su cesionario ("Proveedor") son propiedad y están manejados y no es de ninguna manera asociado con un hospital, la medicina o cualquier otra clínica. • El proveedor proporciona al menos una garantía del fabricante de compresor de tres años en todos sus nebulizadores. • Certifico que la información proporcionada por mí y la solicitud de pago bajo el Título XVIII (Medicare) de xx Xxx del Seguro Social de cualquier otro seguro es verdadera y correcta. • Yo entiendo que soy personalmente responsable al Proveedor por los cargos no pagados en su totalidad por la cobertura del seguro, las responsabilidades deducible o co-pago o, en ausencia de la cobertura del seguro, el saldo total del uso y costumbre cantidad / precio para este equipo hasta la cantidad maxima de 195$. • Autorizo la liberación de todos los registros médicos en relación con el equipo mencionado. • Solicito ...
PLEASE READ AND SIGN. You hereby request that Your Broker maintain a Brokerage Account in the name(s) listed on this Application. You acknowledge that you have received, read and understood the SWST Cash Account Agreement Section of the Customer Information Brochure and you agree to be bound by the terms and conditions of the Agreement that apply to your Brokerage Account, as amended and that you will contact Your Broker regarding any questions that may relate to your account. Under rule 14b-1(c) of the Securities Exchange Act, a broker is required to disclose to an issuer the name, address, and securities positions of our customers who are beneficial owners of that issuer’s securities unless the customer objects. If you object to the disclosure of such information, please check box: By signing this Application, you confirm your intention to reinvest cash credit balances held by SWST in your name, and you further confirm that this cash credit balance is being maintained in your account solely for the purpose of reinvestment. You acknowledge your understanding that cash balances of up to $100,000 are protected by the Securities Investor Protection Corporation (SIPC), but SIPC coverage is not available for funds maintained solely for the purpose of earning interest. "Power of Attorney" not related to limited trading authorization will be accepted if it complies with the POA standards established by Southwest Securities, Inc.
PLEASE READ AND SIGN. I agree to abide by Xxxxxxx Service’s rules & policies, to pay all charges for lost or damaged materials accumulated on my authorized account and to notify Lending Services of any changes uncured. I understand my loaning privileges can be suspended and I also agree to be responsible for all costs of collections including Resource Center staff attorney fees, if applicable. I further agree that all charges and costs may be entered as a civil judgment against me and/or my organization.
PLEASE READ AND SIGN. I, give my consent for psychotherapy services to be provided to , through INSIGHT COUNSELING PROFESSIONALS, PLLC. I understand that my sessions with Insight Counseling Professionals may either be authorized through my EAP or approved through a Managed Care Insurance program. This may mean that I can be seen either free of charge to me, or at reduced rates and/or copayments. I agree to pay all appropriate copayments as well as applicable deductibles and for services disallowed for any reason by my EAP/MC program or insurance company. I may or may not be financially responsible for appointments missed or canceled without 24-hour advance notice. I understand that I will forfeit my allotted EAP session(s) for each appointment missed or canceled without 24-hour advance notice. I agree that if I pay by check, my account will be debited electronically for both the face amount and returned check fee ($35.00) if it is returned unpaid. I also understand that I am financially responsible for any collections fees/court costs involved in collecting my past due account. I understand that if I am unable to keep a scheduled appointment, I will notify Insight Counseling Professionals within at least 24-hours of advanced notice. I understand that I am also financially responsible for all phone calls longer than 15 minutes. Payment is required at the time service is provided; however, insurance information will be obtained at the first session and insurance will be filed as a courtesy to me for sessions following the initial EAP sessions. Release and Assignment: I hereby authorize any plan benefits to be paid directly to Insight Counseling Professionals, PLLC. and I understand that I am financially responsible for non-covered services, including those for which authorization or payment has been denied, either by my EAP/Managed Care plan or other payer. If a claim is made by me or Insight Counseling Professionals to any insurance company or companies, or to any other third party payer, I do not object to the release by mail, fax, telephone, cell phone or computer modem, any records or other information about me, or my child, or the services which are provided, including without limitation, the complete case record, information concerning any personal, psychological and medical history, information concerning billing and payment for such services. I understand that modern communication modalities, such as cell phone, email, and fax, are subject to difficulties. I understand th...
PLEASE READ AND SIGN. By signing this document, it is acknowledged that you have received, read, and understand the Transfer on Death Agreement and Addendum as well as the Customer Information Brochure, which is herein incorporated by reference, and agree to be bound by the terms and conditions contained by both. Applicant’s Signature Date Co-Applicant’s Signature Date
PLEASE READ AND SIGN. I agree to abide by the Lending Services rules & policies, to pay all charges for any lost or damaged library materials accumulated on this card and to notify the Resource Center of any change of employment or loss of card. I understand I am responsible for all materials checked out on this card. Should I fail to return materials and/or promptly pay any charges incurred, I understand my loaning privileges will be suspended and my wages may be garnished for the replacement cost of the materials.
