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Patient admission and registra... FIX PATIENT IDENTIFICATION LABEL HERE UR No: ADM No: SURNAME: Phone: (03) 9411 7111 Fax: (03) 9419 6585 Booking Office: 59 Victoria Parade Fitzroy 3065 hospital.bookings svpm.org.au GIVEN NAMES: SEX:

Alpha kappa rho registration f... Alpha Kappa Alpha Sorority, Incorporated Undergraduate Membership Interest Application (This form must be signed in the presence of a licensed notary. See page III-14 of the application) I understand

Prtb1 form FORM PRTB1 Please as appropriate TENANCY REGISTRATION TENANCY UPDATE Please read the accompanying notes before completing this form. Use CAPITAL LETTERS. Write clearly and accurately within boxes. Please note that an incomplete form will be returned to you. Notes for Completion of Tenancy Registration Form PRTB1 In completing this form use CAPITAL LETTERS. Write clearly and accurately within boxes. Do not join your writing. A separate form must be completed for each tenancy of a dwelling Bord Um Thion ntachta C naithe Pr obh ideacha Private Residential Tenancies Board nd 2 Floor O Connell Bridge House Dublin 2. Tel 353 1 635 0600 Fax E-mail information prtb. ie Part 1 - Details of the Dwelling Tenancy Registration Number see Note A Fee enclosed Address of Rented Dwelling include unit number if property is let in 2 or more units Address Description of Rented Dwelling if the rented dwelling is part of a house or maisonette please tick Part of House along with the type of house e*g* detached house Detached House Bedsit Whole of House RT No fee see Note B Part of House Semi-detached House Flat Maisonette Terraced House Apartment Number of Bed Spaces see Note C Number of occupants Number of Bedrooms Approximate Floor Area in square metres see Note D Landlord - Name and Contact Details if more than 1 landlord involved in this tenancy please complete Part 5 of this Form see also Note E First name Surname Telephone optional Mobile Phone optional PPSN of Landlord see Note F Reproduction of this form is permitted only fully completed forms will be accepted Page 1 of 1 Landlord s Letting Agent if any - Name and Contact Details if the premises is let through an agent Name Agent PPSN or Company Reg*No Local Authority - Name of Area see Note G Tenant - Name and Contact Details if more than 1 tenant involved in this tenancy PPSN of Tenant see Notes F and I Months Years If a lease agreement applies to this tenancy please indicate the term Date tenancy commenced Sub-letting If this tenancy is a sub-letting please tick Rent Amount Frequency of Payment per week Tenant Signature see Note J Date Landlord/Agent Signature see Note K dd/mm/yy Landlord per fortnight per month Agent per year please tick box Page 2 of 2 Name and Contact Details of additional Tenants see Notes F H I and J PPSN Landlord Signature Page 3 of 3 Part 6 - Apartment Blocks/Complexes Only This part of the form should be completed if the dwelling concerned is an apartment in an apartment complex under the operation of a management company. Management Company - Name and Contact Details see Note L Management Agents if any - Name and Contact Details see Note L Part 7 Payment by Credit / Debit Card If you wish to pay your registration fee by credit / debit card please complete the details below Card Type Visa Mastercard Laser Name of Cardholder Card Number Expiry Date Please debit my account by Cardholder Please ensure your address is the same as on your bank/credit card statement Page 4 of 4 For Official Use Only Checklist Before sending this form to the PRTB please check that the tenant s has ve provided their PPSN on the form your own PPSN is on the form you have signed and dated the form you have completed all questions on the form and you have enclosed a cheque for the correct amount and made it payable to the PRTB or provided your credit/debit card details at Part 7.

Mississippi employee s withhol... Form 801001781000 (Rev. 01/18)RESIDENT, NONRESIDENT AND PARTYEAR RESIDENT INCOME TAX INSTRUCTIONS2017INDIVIDUAL INCOME TAX BUREAU PO BOX 1033 JACKSON, MISSISSIPPI 392151033 WWW.DOR.MS.GOVTABLE OF

Completion certificate sample... According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control

Death certificate word format Mail this completed form to: SRC, an Aetna Company Attn: Claim Department Group Life Insurance and Group Accidental Death Benefit PO Box 14079 Request Lexington, KY 40512-4079 (Filing instructions

Ma boating accident form Massachusetts Environmental Police Boating & R.V. Safety Bureau 1 Trowbridge Road Bourne, MA 02532 Phone: (508) 759-0002 Fax: (508) 759-3357 BOATING ACCIDENT REPORT The operator/owner of a vessel

Gift certificate template form Gift Certificate Date Expiration Date This Gift Certificate Entitles To Receive Worth Presented by Authorized Signature Form 10002 Printed by.

Lojack certificate form FOR LOJACK USE ONLY INSTALLATION DATE: VIN #: ADMINISTRATOR: Safe-Guard Warranty Corporation 3500 Piedmont Road NE, Suite 400 Atlanta, GA 30305 PURCHASER: Name: Purchase Date: Vehicle Year, Make,

What does a certificat fo trus... CERTIFICATE OF TRUST EXISTENCE AND AUTHORITY THIS AGREEMENT is made and entered into on JANUARY 8, 2008, between JOHN A. GREEN and NANCY A. GREEN, of the County of MARICOPA, State of ARIZONA, herein

Usps form 3817 2007 2018 Certificate Of Mailing To pay fee affix stamps or meter postage here. This Certificate of Mailing provides evidence that mail has been presented to USPS for mailing. This form may be used for domestic and international mail. From To PS Form 3817 April 2007 PSN 7530-02-000-9065 Postmark Here. Certificate Of Mailing To pay fee affix stamps or meter postage here. This Certificate of Mailing provides evidence that mail has been presented to USPS for mailing.

Request transfer certificate f... REQUEST FOR APPROVAL OF TRANSFER CERTIFICATE LICENSEE TRANSFEROR DATE TRANSFEREE AS A MATERIAL INDUCEMENT FOR THE U.S. SMALL BUSINESS ADMINISTRATION SBA TO CONSENT TO THE TRANSFER OF THE LIMITED PARTNERSHIP INTEREST DESCRIBED BELOW EACH OF THE LICENSEE TRANSFEROR AND TRANSFEREE HEREBY REPRESENTS WARRANTS AND COVENANTS AND AGREES AS FOLLOWS Transferor is a limited partner in Licensee with a commitment of Dollars to Licensee Partnership Interest of which has been contributed to Licensee. In the event of any actual or asserted conflict or inconsistency as between any provisions or terms contained in this Request for Approval of Transfer Certificate and provisions or terms of any other agreement written document or other instrument concerning the Transferred Interest then the provisions or terms contained in this Request for Approval of Transfer Certificate shall govern. The terms conditions obligations representations and warranties contained in this Request for unfunded commitment attributable to the Transferred Interest shall be enforceable by the Licensee and/or SBA in any court of competent jurisdiction and shall not be subject to arbitration notwithstanding any other agreement or provision of any agreement to the contrary. Transferor represents and warrants that it is not in default of its obligations to the Licensee for payment of its Partnership Interest or in default of any other material obligation owed to the Licensee. Transferor and Transferee have entered into an agreement Transfer Agreement under which Transferor proposes to transfer to Transferee percent of Transferor s Partnership Interest including all of Transferor s rights title and interest therein the Transferred Interest. Following such transfer Transferee s ownership interest in Licensee will equal. does not qualify as an Institutional Investor under 13 CFR 107. 50. Transferor does Transferred Interest is lawful including without limitation that the proposed transfer will not violate any federal or state laws governing securities. The Licensee represents and warrants that it does not possess knowledge of any facts about the proposed transfer that would make the transfer unlawful including without limitation facts that the proposed transfer would violate federal or state laws governing securities. Licensee represents and warrants that it is in compliance with all laws and regulations governing Small Business Investment Companies. and will not result in a transfer of Control as that term is defined in SBA s regulations in Part 107 of Title 13 of the Code of Federal Regulations. Under the Transfer Agreement Transferee i accepts the Transferred Interest ii agrees to comply with be bound by and subject to all of the terms conditions and provisions of Licensee s agreement of limited partnership Partnership Agreement iii undertakes and assumes all of Transferor s duties and obligations under the Partnership Agreement including the obligation to contribute any unfunded commitment attributable to the Transferred Interest and iv makes all representations required of a limited partner under the Partnership Agreement.

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