Healthcare | airSlate SignNow

Michigan workforce background... LONG TERM CARE WORKFORCE BACKGROUND CHECK APPLICATION FORM Part 1 Consent Part 2 Applicant Information Part 3 Disclosure Part 4 Conditional Employment Part 5 Applicant Rights Part 6 Disclaimer Effective

Sanofi patienc connection hipp... Form from www.needymeds.org Reset Form Sanofi Patient Connection Phone 1-888-847-4877 Fax 1-888-847-1797 APPLICATION INSTRUCTION GUIDE To ensure that you maximize the full range of services for Sanofi

Under 18 consent form housing... Under 18 Parent Consent for Housing and Dining License Agreement Form 2012-2013 Academic Year Thank you for applying to live on campus at Wayne State University! Please utilize this form to discuss

Privacy consent form United States Senator Barbara Boxer PRIVACY ACT CONSENT FORM The provisions of Public Law 93-579 Privacy Act of 1974 prohibit the disclosure of information of a personal nature from the files of an individual without their consent. Accordingly I authorize the staff of Senator Barbara Boxer to access any and all of my records that relate to the problem stated below. Signature Date To begin processing your case please complete all of the following information Circle One Mr. Mrs. Miss Ms. First Name Last Name Date of Birth Social Security Number Address City ZIP Email Phone Number Federal agency with which you need help Briefly explain the problem or the information desired attach additional pages if necessary Please include copies of any relevant documentation related to your request as attachments to this form* Also include the following information if appropriate. IMMIGRATION OTHER MILITARY Alien Registration Priority Date Form Date filed USCIS Receipt Embassy Case EEO Charge Student Lender Name OPM CSA Branch of Service Rank VA File Number VA Office or Medical Center Please list any other Congressional offices that you have contacted about this issue Print and mail your completed form to Senator Barbara Boxer s Oakland office at Attention Casework Department 70 Washington Street Suite 203 Oakland California 94607 Fax 202. 228. 6866 Despite containing a Washington D*C* area code faxes sent to the above fax line will be received in Oakland. Accordingly I authorize the staff of Senator Barbara Boxer to access any and all of my records that relate to the problem stated below. Signature Date To begin processing your case please complete all of the following information Circle One Mr. Signature Date To begin processing your case please complete all of the following information Circle One Mr. Mrs. Miss Ms. First Name Last Name Date of Birth Social Security Number Address City ZIP Email Phone Number Federal agency with which you need help Briefly explain the problem or the information desired attach additional pages if necessary Please include copies of any relevant documentation related to your request as attachments to this form* Also include the following information if appropriate. Mrs. Miss Ms. First Name Last Name Date of Birth Social Security Number Address City ZIP Email Phone Number Federal agency with which you need help Briefly explain the problem or the information desired attach additional pages if necessary Please include copies of any relevant documentation related to your request as attachments to this form* Also include the following information if appropriate. IMMIGRATION OTHER MILITARY Alien Registration Priority Date Form Date filed USCIS Receipt Embassy Case EEO Charge Student Lender Name OPM CSA Branch of Service Rank VA File Number VA Office or Medical Center Please list any other Congressional offices that you have contacted about this issue Print and mail your completed form to Senator Barbara Boxer s Oakland office at Attention Casework Department 70 Washington Street Suite 203 Oakland California 94607 Fax 202.

Ma dept of housing and communi... Massachusetts Department of Housing and Community Development Resident Notice and Consent Form for State-Aided Public Housing and State Rental Assistance Pursuant to state law Chapter 334 of the Acts of 2006 The Department of Housing and Community Development DHCD must gather compile and report data in order to provide current accurate and detailed information on the number location and residents of assisted housing units including state-aided public housing and recipients of state or federal rental assistance. DHCD will also evaluate the data to ensure that housing choice and inclusive patterns of housing are available across the Commonwealth. In response to the above cited law and regulations at 760 CMR 61. 00 DHCD is requiring local housing authorities administering state-aided public housing and state rental assistance and regional agencies administering state rental assistance to collect and report certain resident household data to DHCD. Much of this information is already collected pursuant to separate authority. DHCD will annually report to the state legislature on its data collection efforts and may provide reports to other interested parties in a manner consistent with privacy laws including provides for the rights of data subjects this includes your right to inspect and copy your personal data and to object to the collection maintenance dissemination use accuracy completeness or relevance of the personal data or type of information held about you. Page 1 of 2 7/11/2008 Please respond to the following data questions 1 What is the race of the head of household Circle all that apply White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other specify 2 Is at least one adult member of the household a racial minority Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander or other minority yes or no 3 Is the head of household Hispanic/Latino yes or no 5 What is the number of children under 6 years of age in the household that reside in the unit years of age that reside in the unit 7 What is the household type Circle one of the following choices below Single/non-Elderly Elderly Related/Single Parent a single parent household with a dependent child or children Related/Two parent a two-parent household with a dependent child or children Other any household not included in the above four definitions including two or more unrelated individuals In signing this consent form you acknowledge that after reading this form you voluntarily provided the information above that you understand that there are no penalties if you do not wish Head of household signature Date. DHCD will also evaluate the data to ensure that housing choice and inclusive patterns of housing are available across the Commonwealth. In response to the above cited law and regulations at 760 CMR 61. 00 DHCD is requiring local housing authorities administering state-aided public housing and state rental assistance and regional agencies administering state rental assistance to collect and report certain resident household data to DHCD.

Texas tdap consent form STIXID Standing Order for Tdap Vaccine OR Declination Consent and Administration of I have read the VIS information about the Tdap Vaccine. I know thi, vaccine is a once in a life-tim. booster and

Alberta consent form ALBERTA CONSENT FORM Tax and Revenue Administration This form authorizes Tax and Revenue Administration to release confidential taxpayer information to a designated third party representative in matters pertaining to applicable legislation. Note This authorization is valid until the taxpayer or authorized signing person of the taxpayer cancels it in writing. Please complete a separate form for each representative. Send the completed form to TAX AND REVENUE ADMINISTRATION 9811 109 STREET EDMONTON AB T5K 2L5 or fax to 780-427-0348. If you have any questions please phone 780-427-3044. If calling long distance within Alberta call 310-0000 then enter 780-427-3044. The purpose of this form is To authorize a third party representative to receive taxpayer information or To cancel a third party representative from receiving taxpayer information 1. Taxpayer Identification Corporate Legal Name Alberta Corporate Account Number CAN Alberta Business Identification Number BIN 2. Authorized Third Party Identification Authorized Individuals Name and/or Name of the Firm Phone Number Address 3. Details of Authorization All Tax Programs Indicate the period for which authorization or cancellation applies OR All Years Corporate Income Tax Tourism Levy Specific Years International Fuel Tax Agreement IFTA Tax Exempt Fuel Users TEFU Prescribed Rebate Offroad Percentages PROP All Years Prior to Other specify 4. Authorized Signature authorized signing officer of the taxpayer Name Date Signed please print Signature Postion Office or Rank This form must be signed by an authorized person of the business such as a director of the corporation* This form will be considered invalid if incomplete or not signed and dated by an authorized person of the business. Please complete a separate form for each representative. Send the completed form to TAX AND REVENUE ADMINISTRATION 9811 109 STREET EDMONTON AB T5K 2L5 or fax to 780-427-0348. If you have any questions please phone 780-427-3044. If calling long distance within Alberta call 310-0000 then enter 780-427-3044. If you have any questions please phone 780-427-3044. If calling long distance within Alberta call 310-0000 then enter 780-427-3044. The purpose of this form is To authorize a third party representative to receive taxpayer information or To cancel a third party representative from receiving taxpayer information 1. The purpose of this form is To authorize a third party representative to receive taxpayer information or To cancel a third party representative from receiving taxpayer information 1. Taxpayer Identification Corporate Legal Name Alberta Corporate Account Number CAN Alberta Business Identification Number BIN 2. Taxpayer Identification Corporate Legal Name Alberta Corporate Account Number CAN Alberta Business Identification Number BIN 2. Authorized Third Party Identification Authorized Individuals Name and/or Name of the Firm Phone Number Address 3. Authorized Third Party Identification Authorized Individuals Name and/or Name of the Firm Phone Number Address 3. Details of Authorization All Tax Programs Indicate the period for which authorization or cancellation applies OR All Years Corporate Income Tax Tourism Levy Specific Years International Fuel Tax Agreement IFTA Tax Exempt Fuel Users TEFU Prescribed Rebate Offroad Percentages PROP All Years Prior to Other specify 4.

Eyelash consent form Eyelash Extensions Consent Form I have agreed to have eyelash extensions applied and/or removed from my eyelashes. Before my qualified professional eyelash technician can perform this procedure I understand I must complete this agreement and provide my consent by signing and dating this 2 page consent form where indicated below. The following conditions may determine that you are not a suitable for eyelash extensions Condition Adverse Reactions Allergic to adhesives glues tapes band aids etc* and gel pads that may cause an allergic reaction Chemotherapy Treatments within the last 6 months Medication for chemotherapy may cause a reaction to the materials used for eyelash extensions Thyroid Medications medication in the system Lasik Surgery less than 4 months must wait 4 weeks post-op exam for medical consent Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area glues gel pads. Blephoroplasty must wait 6 months post-op for medical consent Contact Lenses Glue used to apply the eyelash extensions may get underneath the contact lens and cause corneal abrasion or scratching. Extremely oil skin and hair Natural oils will break-down the adhesives used to bond the eyelash extensions causing the eyelash extensions to fall out www. lashbase. co. uk consent1. pdf Yes No I have the I do not have the I agree to the following I understand there are risks associated with having artificial eyelashes applied to and/or removed from my natural eyelashes. so as not to create excessive weight on the natural eyelash thereby preserving the health growth and natural look of the client s natural eyelashes. I understand as part of the procedure eye irritation eye pain eye itching discomfort and in rare cases eye infection may occur. technician and have the eyelashes removed immediately and consult a physician at my own expense. materials may become dislodged during or after the procedure which may irritate my eyes or require further follow up care. after care instructions can cause the eyelash extensions to fall out. eyes closed for duration of 60-100 minutes during the procedure. I also understand that I will need to be lying in a reclined position* Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean I will not be able to have the procedure performed on my eyes. This agreement will remain in effect for the procedure and all future procedures conducted by my technician for one year from the date of this signed form* I understand that this agreement is binding and that I have read and fully understand all information listed above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form* Client Signature Date Client Printed Name Phone Parent or guardian if under 18 years of age Name and signature. The following conditions may determine that you are not a suitable for eyelash extensions Condition Adverse Reactions Allergic to adhesives glues tapes band aids etc* and gel pads that may cause an allergic reaction Chemotherapy Treatments within the last 6 months Medication for chemotherapy may cause a reaction to the materials used for eyelash extensions Thyroid Medications medication in the system Lasik Surgery less than 4 months must wait 4 weeks post-op exam for medical consent Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area glues gel pads. Blephoroplasty must wait 6 months post-op for medical consent Contact Lenses Glue used to apply the eyelash extensions may get underneath the contact lens and cause corneal abrasion or scratching.

Ncl consent form Parent / Guardian Consent Release Form PARENT/GUARDIAN CONSENT RELEASE FORM ATTENTION GUEST SERVICES DEPARTMENT Minor s Name as appears on birth certificate Street Address Ship City State Zip Voyage Date of Birth Social Security Cabin WHEREAS hereinafter MINOR desires passage on board a Norwegian Cruise Line NCL ship and of such MINOR as his/her parent or legal guardian and WHEREAS the undersigned hereby consent s to such MINOR S passage on an NCL ship and agree s to release and indemnify NCL and its vessels from and against any and all liability caused by said MINOR. In consideration of the mutual undertakings of the parties and other good and valuable considerations the receipt and sufficiency of which are acknowledged the undersigned covenant s and agree s as follows The undersigned hereby authorize s and consent s to the MINOR sailing on board an NCL ship and further hereby authorize s and consent s to the examination diagnosis treatment and care rendered to the MINOR which in the sole opinion of the ship s physician or any other medical personnel acting under his or her supervision may be necessary or appropriate under the circumstances. of the MINOR including emergency air ambulance evacuation if necessary and to indemnify and hold NCL and its vessels harmless from any liability for any and all costs or expenses incurred as a result of the medical treatment of the MINOR* expenses including reasonable attorney s fees suffered by any person or entity including but not limited to other guests NCL and its employees and vessels due to any act or omission of the MINOR while on board and NCL ship whether intentional or not. and hereby acknowledge s and agree s for the undersigned and the MINOR to be fully bound thereby. has/have read and understands this consent and release and fully agree s to all its term* Executed on the day of year. Witness Both parents/legal guardians if shared custody of MINOR must sign* Witnesses must be adults and at least one witness may not be the spouse or blood relative of the parent/legal guardian Agreed to and Accepted by Signature of Minor NCL Faxback Service 1-800-FAX-NCL1/ 1-800-329-6251. of the MINOR including emergency air ambulance evacuation if necessary and to indemnify and hold NCL and its vessels harmless from any liability for any and all costs or expenses incurred as a result of the medical treatment of the MINOR* expenses including reasonable attorney s fees suffered by any person or entity including but not limited to other guests NCL and its employees and vessels due to any act or omission of the MINOR while on board and NCL ship whether intentional or not. and hereby acknowledge s and agree s for the undersigned and the MINOR to be fully bound thereby. has/have read and understands this consent and release and fully agree s to all its term* Executed on the day of year. and hereby acknowledge s and agree s for the undersigned and the MINOR to be fully bound thereby. has/have read and understands this consent and release and fully agree s to all its term* Executed on the day of year. Witness Both parents/legal guardians if shared custody of MINOR must sign* Witnesses must be adults and at least one witness may not be the spouse or blood relative of the parent/legal guardian Agreed to and Accepted by Signature of Minor NCL Faxback Service 1-800-FAX-NCL1/ 1-800-329-6251.

Vfs consent form CONSENT FORM FOR USE OF SERVICES OF VFS Global Services Pvt Ltd. 1. Use of VFS s service is not mandatory. VFS provides its services with the official approval of the Government of Canada* VFS s fees for its services have been approved by the Government of Canada* However it is not mandatory to use VFS s service. Visa and permit applicants may also apply directly to the Canadian High Commission in new Delhi or to the Canadian Consulate General in Chandigarh. 2. Liability VFS is not an agent of the Government of Canada* Although VFS s services are approved by the Government of Canada VFS is a completely independent organization operating under the laws of India and is solely responsible for the provision of its services. including but not limited to breach of confidentiality of personal information related to visa applications arising out of the performance of the VFS s services. The government of Canada is not liable for the physical safekeeping and privacy of documents provided by the visa or permit applicant or anyone else while such documents are in the possession of VFS* 3. Language of services. VFS provides services only in English and certain local languages Service in the French language is available directly from the Canadian High Commission in New Delhi and at the Consulate General in Chandigarh. 4. Protection of personal information In order to obtain the approval of the Government of Canada for its services VFS has promised to respect principles of personal information protection adopted by Canada the European Community the United States and several other countries. VFS will make a copy of the principles it has agreed to available upon request. 5. Consent The user of VFS s services consents as follows I have read this document completely. I hereby confirm that I understand that my use of the services of VFS for the submission of my visa or permit application is not mandatory. I understand that applications may be made directly to the Canadian High Commission in New Delhi or the Canadian Consulate General in Chandigarh without using the services of VFS* I hereby give my consent to VFS to receive documents from me and obtain personal information from me for use in obtaining a Canadian visa or permit. First Applicant Second Applicant NAME printed SIGNATURE ADDRESS DATE Signed at VFS is a service provided by VFS Global Services Pvt Ltd. VFS provides its services with the official approval of the Government of Canada* VFS s fees for its services have been approved by the Government of Canada* However it is not mandatory to use VFS s service. Visa and permit applicants may also apply directly to the Canadian High Commission in new Delhi or to the Canadian Consulate General in Chandigarh. Visa and permit applicants may also apply directly to the Canadian High Commission in new Delhi or to the Canadian Consulate General in Chandigarh. 2. Liability VFS is not an agent of the Government of Canada* Although VFS s services are approved by the Government of Canada VFS is a completely independent organization operating under the laws of India and is solely responsible for the provision of its services.

Consent of agent in the virgin... FORM - RACA12 THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF CORPORATIONS AND TRADEMARKS RESIDENT AGENT FORM CONSENT OF AGENT FOR SERVICE OF PROCESS This writing witnesseth that I the undersigned having been designated by as resident agent of said company upon whom service of process may be made in all suits arising against said company in the Courts of the United States Virgin Islands do hereby consent to act as such agent and that service of process may be made upon me in accordance with Title 13 Virgin Islands Code. IN WITNESS WHEREOF I have hereunto set my signature this day of. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES VIRGIN ISLANDS THAT ALL STATEMENTS CONTAINED IN THIS APPLICATION AND ANY ACCOMPANYING DOCUMENTS ARE TRUE AND CORRECT WITH FULL KNOWLEDGE THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE SUBJECT TO INVESTIGATION AND THAT ANY FALSE OR DISHONEST ANSWER TO ANY QUESTION MAY BE GROUNDS FOR DENIAL OR SUBSEQUENT REVOCATION OF REGISTRATION* SIGNATURE OF RESIDENT AGENT DAYTIME CONTACT NUMBER MAILING ADDRESS PHYSICAL ADDRESS NOTARY ACKNOWLEDGEMENT Subscribed and sworn to before me this day of at Notary Public My Commission Expires.

Physician consent form PHYSICIAN S CONSENT FORM For use of Portable Oxygen Concentrator POC Must be completed and signed by the passenger and passenger s physician Additional information can be found at www. aa*com Physician s Name Address Telephone Fax Customer Information This document is to remain in your personal possession and must be presented to an airline representative upon request. Any changes in oxygen requirements such as a revised flow rate will require an updated statement. You are responsible for knowing how to operate your portable oxygen concentrator POC device ensuring that your device is in good condition and free from damage or excessive wear and tear. and ground connection time where the POC is planned to be used per manufacturer s recommendation for unanticipated delays. Electrical power ports may be available on certain flight but cannot be depended upon to power the device. They are not a substitute for fully charged batteries. I understand and agree with the above information Passenger s Signature Physician Information The following information relates to care. Date who is a patient in my Passenger/Patient name He/She needs to operate a POC device at a flow rate of Liters per minutes LPM corresponding to the pressures of the aircraft under normal operating conditions. Cabins are pressurized to an altitude of 8 000 feet. Make and model of POC FAA Approved Models AirSep LifeStyle RTCA sticker required AirSep FreeStyle AirSep FreeStyle 5 AirSep FOCUS DeVilbiss iGo Inogen One Inogen G2 Inogen One G3 International Biophysics Lifechoice by Inova Labs Inova Labs Lifechoice Activox Invacare Corporation s SOLO2 XPO2 XPO100 XPO100B Oxlife Independence Oxus RS-00400 Precision Medical Easy Pulse PM4150 Phillips/Respironics-SimplyGO Respironics-EverGo SeQual Eclipse Model 1000 SeQual Eclipse 2 Model 1000A and SeQual Eclipse 3 Model 1000B SAROS Model 3000. Patient is able to operate the POC and recognize and respond appropriately to its alarms. Yes or No If the answer is no American Airlines will require the Passenger/Patient to travel with a companion able to perform these functions. Patient will require the use of the device during circle all that apply Physician s Signature Taxi Take-off In-flight Landing. aa*com Physician s Name Address Telephone Fax Customer Information This document is to remain in your personal possession and must be presented to an airline representative upon request. Any changes in oxygen requirements such as a revised flow rate will require an updated statement. You are responsible for knowing how to operate your portable oxygen concentrator POC device ensuring that your device is in good condition and free from damage or excessive wear and tear. Any changes in oxygen requirements such as a revised flow rate will require an updated statement. You are responsible for knowing how to operate your portable oxygen concentrator POC device ensuring that your device is in good condition and free from damage or excessive wear and tear. and ground connection time where the POC is planned to be used per manufacturer s recommendation for unanticipated delays.

Healthcare forms

Browse over 85,000 state-specific fillable forms for all your business and personal needs. Customize legal forms using advanced airSlate SignNow tools.

Get legally binding signatures now!