Please Check One. Entire Hall: 1st Floor Only: Wedding Package:
Please Check One. Box: I am requesting a copy of my own record. I am requesting a copy of the record of another person, and I have attached their written consent. Other – for all other record requests, you must initial at least one permissible use in Part C of this Agreement, and you must check at least one of the following boxes: I am making a one-time request, and I will use the record one time and for one purpose. I am requesting on-line record access. (Skip Part B of this form if you are requesting record access). I am requesting Photo File access. (Skip Part B of this form if you are requesting Photo File access). Name of Requestor (Last) (First) (Middle Initial) Address Driver’s License or Non-Driver ID Number City State Zip Code Email Address Telephone Number ( ) - - Fax Number ( ) - - Requestor is an Authorized Representative of (List Name of Person or Entity): D- List dealer number if dealership Person/Entity Address City State Zip Code
Please Check One. ❑ New Member ❑ Renewal or Current Member Please Print (Head of Last Name Household) First Name Address Apt # City State Zip Telephone ( ) Date of Birth / / Email Address Household members: *List only dependents who are claimed on your tax return. Please list any last name that is different than the Head of Household name above. Last Name (If different from Head of Household) First Name Middle Initial Relationship to Head of Household Date of Birth Spouse Dependent Dependent Dependent Dependent Dependent Dependent Dependent Butte County EMS Ground Ambulance Membership Agreement (Please read this statement carefully, then sign below) I hereby apply for membership in the Butte County EMS Ground Ambulance Membership program for myself and eligible members who live at my address. I understand the enclosed fee provides emergency ambulance care and transportation within the Butte County EMS Ground Ambulance Service area, inter-facility transfers and non-emergency ambulance service as noted below. Coverage begins 3 days after acceptance of the application and extends one full calendar year from that date. Non-emergency ambulance service to hospitals and inter-facility transport from our local hospital to other approved facilities is covered when medically necessary. I understand that Butte County EMS Ground Ambulance Membership program is not insurance, but will provide ambulance service through the Butte County EMS Ambulance Service and will bill whatever insurance or medical benefits I may have. If a member is uninsured at the time of service, the member will be responsible to pay Butte County EMS Ground Ambulance $500.00. I further authorize the release of medical information for the purpose of ambulance insurance billing only. Should a family member or I receive payment from insurance or other medical benefits provider for ambulance service rendered by the Butte County EMS Ground Ambulance Service, I will immediately forward such payment to the Butte County EMS Ground Ambulance Service. Butte County EMS Ground Ambulance Membership program is not solicited from persons who receive Medi-Cal medical benefits and such membership constitutes a voluntary contribution only. I understand that violations of the terms of this agreement may result in immediate cancellation. This membership is non-refundable and non-transferable.
Examples of Please Check One in a sentence
NAME: MEASUREMENTS (For use by the wardrobe department) Height (in Feet) Weight (kilogram) Chest (inches) Waist (inches) Hips (inches) Hair Color Eyes Color Clothes Size (S/M/L) Swimwear/Suit Shoes Size (US) PERSONALITY INTERVIEW COUNTRY NAME FOR PERSONALITY INTERVIEW: Please check one that applies to you.
Member ID: Name of Member: Name of Depositor(s) if other than the member: Phone number of Member/Depositor: Name of Bank, City and State where account is authorized: Your Name Your Address Your City, State & Zip 1000 DATE PAY TO THE ORDER OF $ DOLLARS MEMO SAMPLE Please check one: 🞎 Checking Account 🞎 Savings Account Bank Transit Number: Depositor’s Account Number: I have read and accept the above agreement.
More Definitions of Please Check One
Please Check One. This is a new agreement This is a modified agreement Please terminate my current agreement I authorize my employer to defer the amount(s) above from my paycheck each pay period to be allocated to the 457(b) Vendor(s) as indicated. This amount will remain in effect until Human Resources receives another Salary Reduction Agreement. The amount deferred hereunder will produce a total deduction that does not exceed the limitations of the Internal Revenue Code Section 457(b). Employee is responsible for tax consequences and investment decisions regarding their plan. Signature Date
Please Check One. (Cash or Credit only) Pay in Full for Program – Pay now for the total cost of the twelve week program with included discount price of $900.00. Xxxxxxx Natural Health & Wellness Financing Plan – 4 payments of $250.00 – First payment due upon starting the program, second payment due on 4th visit, third payment due on 8th visit, and the final payment due on the last visit. Total program price of $1,000.00 Care Credit – Care Credit pays upfront the $1,000.00 program and they allow you to set up a payment plan for up to 6 months with NO-interest. You can apply for Care Credit at xxx.xxxxxxxxxx.xxx. I understand that if I would like to continue the program past twelve weeks I will be responsible additional fees. I understand that there will be no refunds made for any costs associated with the program. In addition, if there are any medical contraindications found by the medical staff at the first visit, which will not allow me to continue the program; I will still be responsible for the first visit. Print Name: Legal Signature: Date: 0 XXXXXXX XXXX DRIVE ~ SUITE 490 ~ STERLING, VA ~ 00000 XXXXX (000) 000-0000 ~ FAX (000) 000-0000 Patient Waiver I, , acknowledge that I have been given the choice to have my prescription of Phentermine 37.5mg filled at the pharmacy of my choice or at Xxxxxxx Natural Health & Wellness.
Please Check One. I want my child to check out a calculator from the THS Media Center. I understand that my child and I are personally responsible for the care of this calculator and will return it in working order at the end of the semester or be responsible for the fees listed above. I understand that my child CANNOT receive a diploma or replacement calculator until these fees are paid. I also understand that my child is responsible for having their calculator in class each day. My child already has a TI-83+, TI-84+ or TI-89 Graphing Calculator and therefore will not check one out from the Media Center. I will purchase a TI-83+ or TI-84+ Graphing Calculator for my child. Therefore, my child will not check one out from the Media Center. Parent Signature Date
Please Check One. We are participating members of All Saints Catholic Parish (parish supported) We are not members of ASCP (non-parish supported) I/we have read, understand, and agree to the following:
Please Check One. Xxx-Xxxxx Resident ($0.25/word) _ __ Non-Resident ($0.75/word) Please check the appropriate category for your ad: (One ad category per form.) Lost Found (No charge for Lost & Found ad) ___ ___ ___ ___ Garage Sales/Moving Sales _ _ Items For Sale _ Goods & Services _ Business Opportunity _ ___ ___ ____ Real Estate _ Child Care (Offered or Sought) _ Miscellaneous Wanted ____ ___ ___ ___ Employment Offered (No charge; investment and start-up opportunities qualify as a Business Opportunity ad.) First Issue Date Ad is to Appear: Last Issue Date Ad is to Appear: For Renewals Only: renew existing ad through issue date: Content of Ad: (80-word maximum; be sure to include your phone number and/or address in the ad if applicable.) Total # of Words: x Rate: $ /Per Word = Cost Per Issue $ x # of Issues: = Total Due: Office Use Only
Please Check One. Youth sizes: Adult sizes: □ Med (10-12) □ XS □LG □ LG (14-16) □ SM □X-LG □ X-LG (18-20) □ MD I authorize my child to charge up to $ for miscellaneous expenses during Youth Golfari. All charges should be billed to: Credit Card # Exp. Date VIN# Name on the Card: Authorized Signature: Cash is not needed at camp. All purchases made by your camper will be applied to the credit card provided. I wish to pay by: □ Check □ Visa □ MasterCard □American Express □ Discover Credit Card # Exp. Date VIN # Name on the Card: Authorized Signature: ENROLLMENT OPTIONS □ $2,295.00 Early Booking Rate – Before March 1, 2019 full payment must be received to confirm enrollment. □ $2,495.00 Standard Rate – After March 2, 2019 full payment must be received to confirm enrollment. Would you like to purchase Camp Cancellation Insurance* at a cost of $250.00? Yes □ No□ $250.00 *Camp Cancellation Insurance: May cancel up to the day of arrival to receive your refund, less the cost of insurance. 2019 Application Pine Needles Youth Golfari Health Certificate Please return this completed form to Pine Needles by May 1, 2019. Xxxxx’s Name First Name Last Name Address Street City State Zip Code EMERGENCY PHONE NUMBERS WHERE PARENTS CAN BE REACHED DURING CAMP. Parent(s) or Guardian First Name Last Name Phone (Day) (Eve) (Cell) Insurance Company Name Insurance Policy Number * COPY OF FRONT AND BACK OF INSURANCE CARD IS REQUIRED. Please attach to application. I hereby grant permission for the Pine Needles Youth Golfari Staff to render any treatment/medical care to my child that is deemed reasonably necessary for their health and well being. I also grant permission for the Pine Needles Youth Golfari Staff to render any preventative, first aid or emergency treatment to my child that is deemed reasonably necessary, including over the counter medications for my child’s health and well being. Signature of Parent(s) or Guardian The above-named child has been examined by me and the health history and immunization records have been reviewed. By my signature, I verify that the immunization records are current and there are no apparent health issues that would limit or prohibit this child from participating in any Pine Needles camp activities. Exceptions, Comments, Special Problems, Allergies, Physical Limitations, Etc... Medications Currently Taken (list dosages and schedule): Please note: All medications are to be turned in at check-in to be dispensed with proper supervision. Bring all medications in the o...
Please Check One. [ ] Individual Subscriber [ ] Co-Subscriber (Joint account will be registered as joint tenants with right of survivor ship) [ ] Corporation or Partnership - Please include certified resolution (or similar document) authorizing signature. [ ] Trust - Please include a copy of Trust agreement. [ ] Other -Specify _______________________ PRINT Name: _______________________________ ___________________________________________ ___________________________ (Signature ) Social Security Number (if Co-subscriber) PRINT Name: _______________________________ ___________________________________________ ___________________________ (Signature ) Social Security Number ______________________________________________________________________________ (Address) ______________________________________________________________________________ (Phone Number) (Fax Number) Email ================================================= ACCEPTANCE ========== The foregoing Subscription Agreement is hereby accepted on this ______ day of _____ , _____. Raven Moon International, Inc. By: ____________________________ President ATTEST: By: ____________________________ Secretary