Signature Form. By signing the below, the student and his/her parent/guardian agree to follow and accept: ● Use of Technology Policy (6:235), Guidelines, and corresponding Administrative Procedures (AP1, AP2). ● This Chromebook Agreement (E1) ● The Chromebook Procedures and Information for Students and Parents Guide/Handbook (E2) ● The Website and Social Media Guidelines (above) ● That District 139 owns the Chromebook, software, and issued peripherals ● If the student ceases to be enrolled in Chester CUSD 139, the student/parents (guardians) will return the Chromebook in good working order or pay the full replacement cost of the computer. ● In no event shall District 139 be held liable for any claim of damage, negligence, or breach of duty. Printed Student Name Student Signature Date Printed Parent/Guardian Name
Signature Form. NextEra Energy Solutions, LLC (XXXX) is submitting this proposal to qualify for Performance Contracting. Because the boilerplate “Vendor Agreement” contained in the RFP does not specifically apply to all services that we will provide through the TIPS cooperative, upon selection, we are prepared to negotiate the appropriate vendor contract with the TIPS cooperative to the mutual agreement of both parties. • The unsigned vendor agreement form has been uploaded separately.
Signature Form. Print name(s) of Optionholder: (Must appear exactly as the name(s) appear(s) on the Options) Signature(s) of Optionholder: Date: , 2014 Daytime telephone number: ( ) E-mail address: ANNEX A LOCK-UP AGREEMENT July 14, 2014 Health Insurance Innovations, Inc. 000 Xxxxxx Xxx., Suite 325 Tampa, Florida 33613 Attention: Xxxxxxx X. Xxxxxxxx, Xx., General Counsel Re: Health Insurance Innovations, Inc. (the “Company”)—Restriction on Stock Sales Ladies and Gentlemen: This letter agreement (this “Agreement”) is delivered to you pursuant to the Agreement and Plan of Merger, dated July 14, 2014 (the “Merger Agreement”), among the Company, HealthPocket, Inc. (the “Acquired Company”), SV Merger Sub, Inc. (the “Merger Subsidiary”), Xxxxx Xxxxxxx, Xxxxxxx Xxxx, and the other parties thereto. Capitalized terms used and not otherwise defined herein shall have the meanings ascribed thereto in the Merger Agreement. In consideration of the Merger upon the terms and conditions set forth in the Merger Agreement, the former stockholders and certain option and warrant holders of the Acquired Company will receive a combination of cash and Parent Shares. The undersigned acknowledges and agrees that the execution and delivery of this Agreement by the undersigned is a material inducement to, and condition of, the Company’s consummation of the Merger. In consideration of the Company’s obligations under the Merger Agreement, the undersigned hereby agrees that during the period beginning on the Closing Date and continuing through the third (3rd) anniversary of the Closing Date, the undersigned will not offer, sell, contract to sell, pledge, transfer, or otherwise dispose of, directly or indirectly, any of the Parent Shares issued to the undersigned pursuant to the Merger (the “Lock-Up Shares”), enter into a transaction that would have the same effect, or enter into any swap, hedge or other arrangement that transfers, in whole or in part, any of the economic consequences of ownership of the Lock-Up Shares, without, in each case, the prior written consent of the Company. The restrictions set forth in this paragraph shall lapse as to five percent (5%) of the aggregate number of Lock-Up Shares on each of the following dates: (i) January 14, 2016, (ii) April 14, 2016, (iii) July 14, 2016, (iv) October 14, 2016, (v) January 16, 2017, and (vi) April 14, 2017. The restrictions shall lapse as to all other Lock-Up Shares on July 14, 2017. The restrictions set forth in this paragraph shall not apply...
Signature Form. Print name(s) of registered holder(s): (Must appear exactly as the name(s) appear(s) on the Warrant) Signature(s) of authorized representative(s): Title of authorized representative(s): Date: , 2014 Daytime telephone number: ( ) E-mail address: ANNEX A IMPORTANT INCOME TAX INFORMATION Under federal income tax law, a Holder whose Warrants are surrendered is required to provide the Company with such Holder’s correct Taxpayer Identification Number (“TIN”) on IRS Form W-9 or on the applicable Form W-8 (in the case of non-U.S. persons). If such Holder is an individual, the TIN is his or her social security number. If the Company is not provided with the proper TIN, the Holder may be subject to a penalty imposed by the Internal Revenue Service (the “IRS”). In addition, failure to timely provide a properly completed, signed, and dated IRS Form W-9 may subject a Holder to federal income tax backup withholding (currently at a rate of 28%) on any payments made in connection with the Merger (including in connection with the Escrow Agreement) to such Holder and may subject such Holder to penalties imposed by the IRS. Certain Holders (including, among others, certain corporations and certain foreign individuals) may not subject to these backup withholding and reporting requirements. See the enclosed instructions on IRS Form W-9 for additional information. If backup withholding applies, Parent and/or the Company is required to withhold a percentage (currently at a rate of 28%) of any payments made to the Holder pursuant to the Merger Agreement. Any amount withheld is non-refundable by Parent, Merger Sub, the Company, the Surviving Corporation, Representative, the Paying Agent and/or the Escrow Agent. Purpose of IRS Form W-9 To prevent federal income tax backup withholding with respect to payments made to a Holder with respect to Warrants in connection with the Merger Agreement, a Holder should provide the Paying Agent with his, her or its correct TIN by completing the IRS Form W-9 and certifying that the TIN provided on IRS Form W-9 is correct (or that such holder is awaiting a TIN), that such Holder is a U.S. citizen or other U.S. person (as defined) and that such Holder is not subject to backup withholding because: (i) such holder is exempt from federal backup withholding, or (ii) such holder has not been notified by the IRS that such holder is subject to federal backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has noti...
Signature Form. We have read the rules and the SLAM Cobras Football Contract. We are aware of the standards and regulations governing involvement in extracurricular activities. While acknowledging that not all points are covered by our signature, it does indicate that we have read the document and agree to abide by its terms. Consequently, we are adding our signatures to this document below: Players Name: Players Signature: Date: Parent/Guardian Name: Parent/Guardian Signature: Date:
Signature Form pdf If responding to Part 2, the Vendor Agreement Signature Form (Part 2) must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded to this location. If Vendor has proposed deviations to the Vendor Agreement (Part 2), Vendor may leave the signature line of this page blank and assert so in the Attribute Questions and those shall be addressed during evaluation. Reference Form Reference Form JOC (Parts 1 & 2) Legacy updated.xls The Reference Form must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded to this location. The Reference Form must be uploaded in Excel format. Required Confidentiality Claim Form Claim Form.pdf The Required Confidentiality Claim Form must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded to this location. This is the only way for Vendor to assert confidentiality of any information submitted. Conflict of Interest Questionnaire - Form CIQ No response Do not upload this form unless you have a reportable conflict with TIPS. There is an Attribute entitled “Conflict of Interest Questionnaire Requirement” immediately followed by an Attribute entitled “Conflict of Interest Questionnaire Requirement – Form CIQ – Continued.” Properly respond to those Attributes and only upload this form if applicable/instructed. If upload is required based on your response to those Attributes, the Conflict of Interest Questionnaire – Form CIQ must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded at this location. Disclosure of Lobbying Activities - Standard Form - LLL No response Do not upload this form unless Vendor has reportable lobbying activities. There are Attributes entitled, “2 CFR Part 200 or Federal Provision - Xxxx Anti-Lobbying Amendment – Continued.” Properly respond to those Attributes and only upload this form if applicable/instructed. If upload is required based on your response to those Attributes, the Disclosure of Lobbying Activities – Standard Form - LLL must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded to this location. Current Form W-9 W9 Legacy Signs.pdf Vendor must upload their current IRS Tax Form W-9. The legal name, EIN, and d/b/a's listed should match the information provided herein exactly. This form will...
Signature Form pdf If responding to Part 2, the Vendor Agreement Signature Form (Part 2) must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded to this location. If Vendor has proposed deviations to the Vendor Agreement (Part 2), Vendor may leave the signature line of this page blank and assert so in the Attribute Questions and those shall be addressed during evaluation. Reference Form Reference Form JOC (Parts 1 & 2).xls The Reference Form must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded to this location. The Reference Form must be uploaded in Excel format.
Signature Form pdf If you have not taken exception or deviation to the agreement language in the solicitation attributes, download the AGREEMENT SIGNATURE FORM from the "ATTACHMENTS" tab. This PDF document is a fillable form. Download the document to your computer, fill in the requested company information, print the file, SIGN the form, SCAN the completed and signed AGREEMENT SIGNATURE FORM, and upload here. If you have taken exception to any of the agreement language and noted the exception in the deviations section of the attributes for the agreement, complete the AGREEMENT SIGNATURE FORM, but DO NOT SIGN until those deviations have been negotiated and resolved with TIPS management. Upload the unsigned form here, because this is a required document. Pricing Spreadsheet #1 Region 8 TIPS Medical Equipment, Supplies and Services 200804_Pricing_Form_1.xlsx The vendor must download the PRICING SPREADSHEET SHEET from the attachment tab, fill in the requested information and upload the completed spreadsheet. DO NOT UPLOAD encrypted or password protected files. Pricing Spreadsheet #2 UNIPAK CORP. 200804_Pricing_Form_2.xlsx The vendor must download the PRICING SPREADSHEET SHEET from the attachment tab, fill in the requested information and upload the completed spreadsheet. DO NOT UPLOAD encrypted or password protected files. References Region 8 TIPS Reference_Form.xls The vendor must download the References spreadsheet from the attachment tab, fill in the requested information and upload the completed spreadsheet. DO NOT UPLOAD encrypted or password protected files. Proposed Goods and Services Unipak Corp Catalog PERSONAL PROTECTIVE EQUIPMENT (PPE) 5% Discount.pdf Please upload one or more documents or sheets describing your offerings, line cards, catalogs, links to offerings OR list links to your offerings that illustrate the catalog of proposed lines of goods and or services you carry and offer under this proposal. I does not have to be exhaustive but should, at a minimum tell us what you are offering. It could be as simple as a sheet with your link to your online catalog of goods and services. D/M/WBE Certification OPTIONAL No response D/M/WBE Certification documentation may be scanned and uploaded if you desire to claim your status as one of the identified enterprises. (Disadvantaged Business Enterprise, Minority Business Enterprise and/or Woman Business Enterprise) If vendor has more than one certification scan into one document. (PDF Format ONLY) DO NOT UPLOAD encrypted ...
Signature Form. Add Title - Information Sharing Agreement By becoming a signatory to this agreement, Partner organisations are committing to: Apply the standards that are prescribed in guidance and Codes of Practice issued by the Information Commissioner’s Office and. xxxxx://xxx.xxx.xx/for-organisations/ Comply with the provisions of Data Protection legislation which includes, but not limited to: o The General Data Protection Regulation (GDPR) o Data Protection Act 2018 (DPA) o Privacy and Electronic Communications Regulations (PECR) o Digital Economy Act 2017 (DEA) Follow the standards prescribed by the Agreement document which includes processes for sharing information on both a routine and ad-hoc basis. All Partner organisations agree to be responsible for ensuring measures are in place to guarantee the security and integrity of data and that stuff are sufficiently trained to understands their responsibilities and comply with the law. Organisations will recognise that this document encourages sharing of data, but does not alter the statutory duties of those organisations signed up to it. Organisation: Organisation Name Information Asset Owner: Name Email X Date of Signature Caldicott Guardian / Senior Information Risk Owner / Data Protection Officer: Name Email X Date of Signature Signature forms will be kept in a central location held by the Parties Appendix 2 Data Items Data Type Data Source Level (Statutor y or Non- statutory ) Type of Informatio n Why Frequenc y Who accesses this data? Pupil contextual School MIS Non Pupil identifiers, Address, Start & End Date, SEN provision, SEN Needs, Attendance Feeds to LA’s Central Pupil database to provide Children’s Teams with up to date pupil level data to assist with their business function. Daily Education Division Teams Children’s Hub Locality Teams Social Care Teams Performance Team Commissionin g Team Sensitive Pupil Contextual School MIS Non Ethnicity, Religion, Home Language Feed to LA’s Central Pupil database to provide Children’s Teams with up to date pupil level data to assist with their business functions and ensure equality of services Daily Education Division Teams Children’s Hub Locality Teams Social Care Teams Performance Team Commissionin g Team Pupil Premium Excel Non Pupil Premium flag Monitoring/Suppo rt Annually Education Division Teams Finance Performance team EY Headcount Establishme nt MIS Non Child identifiers, address Nursery Education Funding Monthly Performance Team Senior FNE Officer & Suppor...
Signature Form
