Print Name. Signature: Date:
Print Name. Age: Date of Birth: / / Male Female Home Address: Home Tel.: ( ) X / / Signature of Participant Date Signed
Print Name. Notary Public /s/ Patricia A. Frank Commission Nx.: My Commission Expires: STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this 1st day of March, 2000, by Jeffery B. Weinress, as President and Assistant Secretary of eXGNT, XXX., x Xxxxxxxx corporation, on behalf of said corporation. Said person (check one) |x| is personally known to me, |_| produced a driver's license (issued by a state of the United States within the last five (5) years) as identification, or |_| produced other identification, to wit:_______________________.
Examples of Print Name in a sentence
NOTARY PUBLIC, STATE OF WI Print Name: My commission expires: Dated this day of , 20 .
OWNER WASHOE COUNTY SCHOOL DISTRICT Signature: Print Name: Title: Date: CONSULTANT CONSTRUCTION MATERIALS ENGINEERS, INC.
By: Print Name: Print Name: Title: Title: EXHIBIT A Description of Services: Research Objectives Visit Orlando would like to track the sentiment of American travelers with specific focus on sentiment around Orlando, FL.
CITY: OTAY: City of Chula Vista, Otay Landfill, Inc., a municipal corporation a California Corporation By: Xxxxxx Xxx, Mayor By: [Print Name and Title] Attest: Xxxxx Xxxxxx, City Clerk By: Approved as to form by [Print Name and Title] Xxxx X.
NOTARY PUBLIC, STATE OF WI Print Name: My commission expires: TOWN OF DELAFIELD WAUKESHA COUNTY, WISCONSIN Xxxxxx Xxxxxxx, TOWN Chair Xxxxxx Xxxxx, TOWN Clerk STATE OF WISCONSIN ) )ss.
More Definitions of Print Name
Print Name. Print Name:___________________________ Title:________________________ Residence Address: 28 Georgian Lane Darien CT 00000 City State Zip Code Mail Address: Ardsley Partners, 646 Steamboat Rd. Greenwich CT 00000 City State Zip Code Telephone: 203-863-1414 Xxxxxmile: 203-629-8768 Tax Identification or Xxxxxx Xecurity Number ###-##-#### Number of Shares to be Purchased: 15,000 shares Total Purchase Price $ 78,750.00 (ACKNOWLEDGMENT FOR INDIVIDUAL SUBSCRIBER) STATE OF CONNECTICUT ss. ss.: COUNTY OF FAIRFIELD ss. On this 2nd day of September, 1997, before me personally appeared David D. May, to me known to be the individual described in and who xxxxxxxx xxx foregoing instrument, and duly acknowledged to me that (he) executed the same as (his) free act and deed. /s/ KEVIN M. MCCORMACK Notary Xxxxxx My Commission Expires: 2/28/1998 [SEAL] (ACKNOWLEDGMENT FOR CORPORATE SUBSCRIBER) STATE OF ____________ ss. ss.: COUNTY OF __________ ss. On this _____ day of ___________________, 19__, before me appeared ______________, to me personally known, who, being by me duly sworn (or affirmed), did say and acknowledge that he is the ______________ of ________________________, that the seal affixed to said instrument is the corporate seal of said corporation and that said instrument was signed and sealed on behalf of said corporation by authority of its board of directors, and that the execution of the said instrument is the free act and deed of said corporation. [SEAL] ______________________________________ Officer ______________________________________ Title ______________________________________ Notary Public My Commission Expires: _______________ The Company and Subscriber have executed this Subscription Agreement on the date first above written. THE COMPANY: INTELECT COMMUNICATIONS SYSTEMS LIMITED By: /s/ EDWIN J. DUCAYET, JR. Edwin J. Ducayet, Jr., Vice President XXXXXXXXXX: Xx: /s/ TIMOTHX XXXXXXXX (Xxxxxxxtion, Partnership or (Indivixxxx Xxxxxxxxxx) Trust Signature) ______________________________ /s/ TIMOTHY MCCOLLUM (Print Name of Entity) (Sixxxxxxx) Print Name: Timothy McCollum By:___________________________ ______________________________________ (Signature) (Signature)
Print Name. Signature: Title: Date: SWIFT Contract No.
Print Name. Email Address: Signature of Patient/Parent/Guardian: Please return to your SMG Physician Office or Mail to: HIMS Manager – 000 Xxxxxx Xxxxxx, Xxx Xxxxxxxxxx, XX 00000 Name: Date of Birth: Date: Summit Medical Group is participating in the U.S. Department of Health and Human Services’ "Meaningful Use" program in order to provide better patient care. This program will lead to improved electronic communications and a more complete medical record for our patients. As part of this program, we are required to collect patient information such as race, ethnicity and primary language. If you prefer not to share this information, please feel free to choose the option “I Prefer Not to Report”. Please choose one from each section. Race*: Ethnicity*: □ American Indian or Alaska Native □ Hispanic or Latino □ Asian □ Not Hispanic or Latino □ Black or African American □ I Prefer Not to Report □ Native Hawaiian or Other Pacific Islander □ White □ Unknown or Other □ I Prefer Not to Report Primary Language: □ English □ German □ Spanish □ Italian □ Portuguese □ Polish □ French □ Other Language □ I Prefer Not to Report *The choices of Race and Ethnicity are consistent with choices used in US Census surveys. See page 2 for the US government’s definitions of Race and Ethnicity. Summit Medical Group will soon offer our patients online access to certain portions of their personal health records through a “patient portal”. In addition, we will also soon provide a secure, HIPAA/HITECH compliant, electronic means for communicating with your physician and health care providers. If you are interested in participating, please provide us with your email address so we may alert you when this new patient portal is available. Your email address will not be shared with any entity outside the Summit Medical Group. There is no charge for such participation and participation is entirely optional. Email address: Definitions of Race and Ethnicity as defined by the US Government: American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American. A person having origins in any of the black...
Print Name. Sign: Date: Space: Payment: $ XX Xxxx CK#
Print Name. Address: Card Number: Date: Time: Signature:
Print Name. School/Department: _________________ Date of desired absence: ___________________ I understand that I may purchase 2 days a year at $65 PER DAY, the cost will be deducted from my paycheck. Employee Signature: Date request submitted: Principal/Supervisor: Date approved: An employee who does not turn in an approved form for any extra personal leave taken, or who has already taken their Extra Personal Leave allotment will be charged Loss of Pay at their normal daily rate. Application for Recertification Credit Reimbursement Guidelines:
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