AGENT AUTHORIZATION FORM I/We, (Print Bidder name) , Do hereby authorize (print agent’s name), , to act as my/our agent to execute any petitions or other documents necessary to affect the CONTRACT approval PROCESS more specifically described as follows, (IFB NUMBER AND TITLE) , and to appear on my/our behalf before any administrative or legislative body in the county considering this CONTRACT and to act in all respects as our agent in matters pertaining TO THIS CONTRACT. Signature of Bidder Date STATE OF FLORIDA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐Personally Known; OR ☐Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) LEASED EMPLOYEE AFFIDAVIT I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure. I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing arrangement. I agree to notify the County in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the County with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any County jobsite. I further agree to notify the County if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement. I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below: Name of Employee Leasing Company: Workers’ Compensation Carrier: A.M. Best Rating of Carrier: Inception Date of Leasing Arrangement: I further agree to notify the County in the event that I switch employee-leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the County that documents the change of carrier. Name of Contractor: Signature of Owner/Officer: Title: Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint venture, please be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVER, IF THE BIDDER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE
Licenses and Similar Authorizations The Contractor, at no expense to the City, shall secure and maintain in full force and effect during the term of this Contract all required licenses, permits, and similar legal authorizations, and comply with all related requirements.
Authorization, Etc This Agreement and the Notes have been duly authorized by all necessary corporate action on the part of the Company, and this Agreement constitutes, and upon execution and delivery thereof each Note will constitute, a legal, valid and binding obligation of the Company enforceable against the Company in accordance with its terms, except as such enforceability may be limited by (i) applicable bankruptcy, insolvency, reorganization, moratorium or other similar laws affecting the enforcement of creditors’ rights generally and (ii) general principles of equity (regardless of whether such enforceability is considered in a proceeding in equity or at law).
Payment Authorization I authorize Xxxxx Management to collect payment of the application fee and application deposit in the amounts specified under paragraph 3 of the Disclosures.
Supplemental Work Authorizations Before additional work may be performed or additional costs incurred, a change in a work authorization shall be enacted by a written supplemental work authorization in the form identified and attached hereto as Attachment D. Both parties must execute a supplemental work authorization within the period of performance specified in the work authorization. The State shall not be responsible for actions by the Engineer or any costs incurred by the Engineer relating to additional work not directly associated with the performance or prior to the execution of the work authorization. The Engineer shall allow adequate time for review and approval of the supplemental work authorization by the State prior to expiration of the work authorization. Any supplemental work authorization must be executed by both parties within the time period established in Article 2 of the contract, (Contract Period). Under no circumstances will a work authorization be allowed to extend beyond the contract's expiration date or will the total amount of funds exceed the maximum amount payable set forth in Article 3A of the contract (Compensation).
WORK AUTHORIZATIONS The State will issue work authorizations using the form included in Attachment D (Work Authorizations and Supplemental Work Authorizations) to authorize all work under this contract. The Engineer must sign and return a work authorization within seven (7) working days after receipt. Refusal to accept a work authorization may be grounds for termination of the contract. The State shall not be responsible for actions by the Engineer or any costs incurred by the Engineer relating to work not directly associated with or prior to the execution of a work authorization. Terms and conditions governing the use of work authorizations are set forth in Attachment A, General Provisions, Article 1.
LEGAL AUTHORIZATION (a) The Sub-Recipient certifies that it has the legal authority to receive the funds under this Agreement and that its governing body has authorized the execution and acceptance of this Agreement. The Sub-Recipient also certifies that the undersigned person has the authority to legally execute and bind Sub-Recipient to the terms of this Agreement.
Information Release Authorization Throughout the Term, you authorize DES to obtain information from the DSP that includes, but is not limited to, your account name, account number, billing address, service address, telephone number, standard offer service type, meter readings, and, when charges hereunder are included on your DSP xxxx, your billing and payment information. You authorize DES to release such information to third parties, including affiliates that need to know such information in connection with your Retail Power service. These authorizations will remain in effect as long as this Agreement is in effect.
Network Authorization For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section.
Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.
