STATEMENT OF APPLICANT. The Keyholder states that all the information which is provided in this Application/Agreement is true in every respect, and understand that any false, misleading or forged statement made in this document or in connection with this application, or failure to provide relevant information, may be grounds for denial of the application and/or revocation of any Service access or other privileges granted to me. KEYHOLDER/Applicant: (Print name) (Signature) Date Keyholder’s email Xxxxxxxxx’s preferred phone number MLS Company Name Registered with MLS (DBA) MLS Firm # Print Name of Authorized Representative of Company Signature of Authorized Representative of Company Date Relationship of Authorized Representative to Company (e.g. Principal Broker, Manager): Company Legal Name (if different from name above): _ Company Address and City Info: KEY Activation Fee $95.00 + Tax: $99.75 (5%) for Winnebago County Firms FOR MLS OFFICE USE: Agent Key # Assigned Date Assigned Check # Amount $ Name on Check: Received Date: $100.23 (5.5%) for ALL other County Firms Charge: (VISA / MasterCard accepted) Card # Exp. Date Amount $ Print Name As Appears On Card Cardholder’s Signature Date Cardholder’s Address
STATEMENT OF APPLICANT. I/We agree that the Contract I/we have applied for shall not take effect until the later of (i) the issuance of the Contract, or (2) receipt by the Company at its Annuity Service Office of the first payment required under the Contract. The information herein is true and complete to the best of my/our knowledge and belief and is correctly recorded. I/We agree to be bound by the representations made in this application. The Contract I/we have applied for is suitable for my/our insurance investment objectives, financial situation and needs. I/We understand that unless I/we elect otherwise in the Remarks section, the Maturity Date will be the later of the Annuitant's 85th birthday, or 10 years from the Contract Date (IRAs and certain qualified retirement plans may require distributions to begin by age 70 1/2). I/WE ACKNOWLEDGE RECEIPT OF THE MOST CURRENT PROSPECTUS AND UNDERSTAND THAT ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THE CONTRACT APPLIED FOR, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. ------------------------------------------------------------ Signed in (State) ------------------------------------------------------------ Date Signed ------------------------------------------------------------ Signature of Owner/Applicant ------------------------------------------------------------ Signature of Co-Owner ------------------------------------------------------------ Signature of Annuitant (if different from Owner) ------------------------------------------------------------ Signature of Co-Annuitant (if different from Co-Owner) ------------------------------------------------------------ Signature of Irrevocable Beneficiary (if designated) STATEMENT OF AGENT:
STATEMENT OF APPLICANT. I have read the LBSC range safety rules. I understand these rules and agree to abide by them when on club property. I have received a copy of the LBSC range safety rules. I agree to be bound by the Hold Harmless agreement. I understand that the LBSC board may terminate my membership to the LBSC for violations of the LBSC range safety rules or Hold Harmless agreement or any other reason deemed detrimental to the LBSC. Applicants Signature Todays Date Name: Address: Phone: City: Email: State: Date of Birth: Zip: NRA# and Expiration date: Membership Renewal: ◻Family Membership $80 ◻Senior Member $50 Volunteer ◻ Please check box if willing to volunteer for different activities or events Renewal form and full payment must be postmarked by March 1st, 2021 to maintain continuity of membership. Make Sure to Sign this form and Return with Payment!!
STATEMENT OF APPLICANT. The Keyholder and Participant state that all the information which is provided in this Application/Agreement is true in every respect, and understand that any false, misleading or forged statement made in this document or in connection with this application, or failure to provide relevant information, may be grounds for denial of the application and/or revocation of any LockBox System access or other privileges granted to me. KEYHOLDER/Applicant: KEYHOLDER/Applicant: (Print name) (Signature) PARTICIPANT Broker or Appraiser: PARTICIPANT Broker or Appraiser (Print name) (Signature) Company Name Company ID # Address: Phone: Fax: Date: Date: Email: Email PLEASE COPY and KEEP FOR YOUR RECORDS - Return all 5 pages to RANW MLS FOR OFFICE USE: Agent # Key # Rev. August 2005 Date Assigned: Amount $ Check #
