Vendor Agreement Signature Form (Part 1)
Signature of witness Address of Witness
Counterpart Signature This Agreement may be signed in counterpart, and the signed copies will, when attached, constitute an original Agreement.
Counterpart Execution This Agreement may be executed in any number of counterparts with the same effect as if all of the Members had signed the same document. All counterparts shall be construed together and shall constitute one agreement.
Signature This Section 2 and the exercise form attached hereto set forth the totality of the procedures required of the Holder in order to exercise this Purchase Warrant. Without limiting the preceding sentences, no ink-original exercise form shall be required, nor shall any medallion guarantee (or other type of guarantee or notarization) of any exercise form be required in order to exercise this Purchase Warrant. No additional legal opinion, other information or instructions shall be required of the Holder to exercise this Purchase Warrant. The Company shall honor exercises of this Purchase Warrant and shall deliver Shares underlying this Purchase Warrant in accordance with the terms, conditions and time periods set forth herein.
Student Signature By signing this contract, Resident agrees to pay the contract amount (room, board and association fees) in accordance with Addendum B: Rate and Payment Schedule. Resident may pay the full amount due prior to the due date, at the Resident’s election.
Signature Authority By submitting this Response, Respondent represents and warrants that the individual submitting this document and the documents made part of this Response is authorized to sign such documents on behalf of the Respondent and to bind the Respondent under any contract that may result from the submission of this Response. Signature Page Follows Authorized representative on behalf of Respondent must complete and sign the following: East Texas Border Health Clinic dba Genesis PrimeCare Legal Name of Respondent Genesis PrimeCare Assumed Business Name of Respondent, if applicable (d/b/a or ‘doing business as’) Xxxxxxxx, Xxxx, Xxxxx Texas County(s) for Assumed Business Name (d/b/a or ‘doing business as’) Attach Assumed Name Certificate(s) filed with the Texas Secretary of State and Assumed Name Certificate(s), if any, for each Texas County Where Assumed Name Certificate(s) has been filed. S gnature o ut or zed Representative Date Signed Xxxxx Xxxxxxx Chief Executive Officer Printed Name of Authorized Representative First, Middle Name or Initial, and Last Name Title of Authorized Representative 000 Xxxxx Xxxxx Xxxx. Marshall, Texas 75670-4260 Physical Street Address City, State, Zip Code PO Box 1326 Marshall, TX 75671 Mailing Address, if different City, State, Zip Code (000) 000-0000 (000) 000-0000 Phone Number Fax Number xxxxx.xxxxxxx@xxxxxxxxxxxxxxxx.xxx 60868360 Email Address DUNS Number 00-0000000 30538912 Federal Employer Identification Number Texas Identification Number (TIN) 000000000 000000000 Texas Franchise Tax Number Texas Secretary of State Filing Number XLLDXR5196J7 XXX.xxx Unique Entity Identifier (UEI) ASSURANCES - NON-CONSTRUCTION PROGRAMS OMB Number: 4040-0007 Expiration Date: 02/28/2025 Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant, I certify that the applicant: