Please Check One definition

Please Check One. Entire Hall:

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 Last Name (If different from Head of Household) First Name Middle Initial Relationship to Head of Household Date of Birth Dependent Dependent Dependent Dependent Dependent Dependent Dependent I hereby apply for membership in the Colusa County 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 Colusa County 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 Colusa County Ground Ambulance Membership program is not insurance, but will provide ambulance service through the Colusa County 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 Colusa County 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 Colusa County Ground Ambulance Service, I will immediately forward such payment to the Colusa County Ground Ambulance Service. Colusa County 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

• Legal Name of Vendor: DBA Name (if applicable): Address: Officer’s Signature: Print Name and Title: **********************************************************RESIDENT CERTIFICATE Please Check One: Resident Vendor: Vendor has paid unemployment taxes or income taxes in this state during the last twelve calendar months immediately preceding the submission of this Quotation, has a business address in this state and has stated in this Quotation whether the bidder is a “resident bidder” under ORS279A.120(1)(b).

• Please Check One) Some refuge uses are exempted from an appropriateness review [603 FW 1.2; 603 FW 1.2(A)].

• Agreed by: Firm Name: Address: ***************************************** Resident Certificate Please Check One: ❑ Resident Vendor: Vendor has paid unemployment taxes and income taxes in this state during the last twelve calendar months immediately preceding the submission of this proposal.Or❑ Non-resident Vendor: Vendor does not qualify under requirement stated above.

• Please Check One: _ Resident Proposer: Proposer has paid unemployment taxes or income taxes in this state during the last twelve calendar months immediately preceding the submission of this proposal, has a business address in this state and has stated in this proposal whether Proposer is a “resident bidder” under ORS 279A.120(1)(b).

• Hepatitis B Immunization Consent/Refusal Form Please Check One:_ YES, I want to receive the Hepatitis B Vaccine.

More Definitions of Please Check One

Please Check One. Band Member Guard Member Please Check One: Returning Member New Member Check Number Check Amount Parent/Guardian Phone_

Please Check One. (Cash or Credit only)

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.

Please Check One. We are participating members of All Saints Catholic Parish (parish supported)

Please Check One. Xxx-Xxxxx Resident ($0.25/word) _ __ Non-Resident ($0.75/word)

Please Check One. Youth sizes: Adult sizes: Would you like to purchase Camp Cancellation Insurance* at a cost of $250.00?

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