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Form preview North carolina realtor form 20... EXCLUSIVE BUYER AGENCY AGREEMENT Consult 'Guidelines' (Form 201G) for guidance in completing this form This EXCLUSIVE BUYER AGENCY AGREEMENT ('Agreement') is entered into (Date)
Form preview Net 30 terms order form APPLICATION FOR CREDIT Terms are Net 30 Days, OAC Name: Division: Date: / / Year Established: Years at this address: Company or Individual Applying for Credit Physical Address: City/State/Zip: Phone:
Form preview Delegation of service agreemen... PHYSICIAN ASSISTANT DELEGATION OF SERVICES AGREEMENT A Delegation of Services Agreement is to be maintained at each practice site and is to be available to DOPL upon request. In order to prescribe controlled substances the physician assistant must have obtained his or her own controlled substance license and DEA registration. The physician assistant may not use his or her supervising physicians controlled substance licenses or DEA registrations. PROCEDURES ADDRESSING SITUATIONS OUTSIDE THE PHYSICIAN ASSISTANT S SCOPE OF PRACTICE PROCEDURES FOR PROVIDING BACKUP FOR THE PHYSICIAN ASSISTANT IN EMERGENCY SITUATIONS ADDITIONAL CONSIDERATIONS RELATING TO OUR PRACTICE Signature of Physician Assistant Date of Signature Signature of Supervising Physician NOTE It is unprofessional conduct under the Physician Assistant Practice Act to fail to reflects current practices or to fail to make the Delegation of Services Agreement. PRESCRIBING OF CONTROLLED SUBSTANCES schedules of controlled substances and a current DEA registration covering the appropriate is within the prescriptive practice of the supervising physician and also within the delegated prescribing stated in the delegation of services agreement and the supervising physician co-signs any medical chart record of a prescription of a Schedule 2 or Schedule 3 controlled substance made by the physician assistant. In order to prescribe controlled substances the physician assistant must have obtained his or her own controlled substance license and DEA registration. The physician assistant may not use his or her supervising physicians controlled substance licenses or DEA registrations. Physician assistants may authenticate with their signature any form that may be authenticated by a physician signature. PRESCRIBING OF CONTROLLED SUBSTANCES schedules of controlled substances and a current DEA registration covering the appropriate is within the prescriptive practice of the supervising physician and also within the delegated prescribing stated in the delegation of services agreement and the supervising physician co-signs any medical chart record of a prescription of a Schedule 2 or Schedule 3 controlled substance made by the physician assistant. It consists of written criteria jointly developed by a physician assistant s supervising physician and any substitute supervising physicians and the the supervising physicians to assist in the management of illnesses and injuries common to the physician s scope of practice. The following information must be legible. Use additional sheets if necessary. DO NOT SUBMIT YOUR DELEGATION OF SERVICES AGREEMENTS TO DOPL WITH YOUR APPLICATION FOR LICENSURE. Supervising Physician Name Utah License Number Substitute Supervising Physician s Name PRACTICE SITE S Name of Facility Address City State Zip DEGREE AND MEANS OF SUPERVISION the health care needs of the practice population and ensure that the patient s health safety and welfare will not be adversely compromised. There shall be a method of immediate consultation by electronic means whenever the physician assistant is not under the direct supervision of the 100 direct supervision. There shall be a method of immediate consultation by electronic means whenever the physician assistant is not under the direct supervision of the supervising physician. FREQUENCY AND MECHANISM OF CHART REVIEW The degree of onsite supervision shall be outlined in the Delegation of Services Agreement maintained at the site of practice. Physician assistants may authenticate with their signature any form that may be authenticated by a physician signature.
Form preview Human care agreement form Government of the District of Columbia Department on Disability Services HUMAN CARE AGREEMENT CONTRACTOR QUALIFICATIONS RECORD STATUTORY AND REGULATORY AUTHORITY The Procurement Practices Human Care
Form preview Florida commissary letter of a... Florida Department of Agriculture and Consumer Services Division of Food Safety COMMISSARY LETTER OF AGREEMENT ADAM H. PUTNAM COMMISSIONER 5K-4. 002 and 5K-4. 20 F*A. C. Phone 850 245-5520 This form is to be filled out and given to the FDACS inspector in the field and submitted as part of a mobile food establishment permit application or with a package ice plant self-vending permit application that requires a commissary. SECTION 1 MOBILE FOOD ESTABLISHMENT MFE INFORMATION Owner Name Phone Number include area code Owner Mailing Address Permit Number City Zip Code 4 optional County I hereby certify the provided information is correct and understand permit approval is contingent upon verification of an approved commissary. Signature owner of MFE Print Name owner of MFE Date SECTION 2 PRIMARY COMMISSARY INFORMATION Primary Commissary Name Commissary Address Primary Phone Number include area code Commissary License/Permit Number Primary E-Mail Address Licensed By check one Department of Business and Professional Regulation Department of Agriculture Consumer Services Wastewater Disposal of Municipal/Utility On-site Well Supplier Name Septic Tank System Other Water Supply of Primary Commissary Department of Health Package Plant I intend to provide the following activities at this commissary Dish or equipment washing Yes No Storing of food and dry goods room temperature Dumping wastewater Cold Storage of food including ice and drinks Receiving potable water Cooking and/or reheating food Washing the outside of the vehicle Three compartment sink Restroom facilities Other Describe below Describe other activities here Signing this document will allow FDACS Food Inspectors entry to my business during normal hours of operation for evaluation of facilities. Print Name of Person in Charge of Commissary Are additional commissaries used DACS-14223 Rev* 07/08 Page 1 of 2 Signature of Person in Charge of Commissary No If yes List additional commissaries on next page use as many pages needed* SECTION 3 ---ADDITIONAL COMMISSARIES Permit/Licensed Licensed By check one FDACS DOH DBPR. PUTNAM COMMISSIONER 5K-4. 002 and 5K-4. 20 F*A. C. Phone 850 245-5520 This form is to be filled out and given to the FDACS inspector in the field and submitted as part of a mobile food establishment permit application or with a package ice plant self-vending permit application that requires a commissary. SECTION 1 MOBILE FOOD ESTABLISHMENT MFE INFORMATION Owner Name Phone Number include area code Owner Mailing Address Permit Number City Zip Code 4 optional County I hereby certify the provided information is correct and understand permit approval is contingent upon verification of an approved commissary. SECTION 1 MOBILE FOOD ESTABLISHMENT MFE INFORMATION Owner Name Phone Number include area code Owner Mailing Address Permit Number City Zip Code 4 optional County I hereby certify the provided information is correct and understand permit approval is contingent upon verification of an approved commissary. Signature owner of MFE Print Name owner of MFE Date SECTION 2 PRIMARY COMMISSARY INFORMATION Primary Commissary Name Commissary Address Primary Phone Number include area code Commissary License/Permit Number Primary E-Mail Address Licensed By check one Department of Business and Professional Regulation Department of Agriculture Consumer Services Wastewater Disposal of Municipal/Utility On-site Well Supplier Name Septic Tank System Other Water Supply of Primary Commissary Department of Health Package Plant I intend to provide the following activities at this commissary Dish or equipment washing Yes No Storing of food and dry goods room temperature Dumping wastewater Cold Storage of food including ice and drinks Receiving potable water Cooking and/or reheating food Washing the outside of the vehicle Three compartment sink Restroom facilities Other Describe below Describe other activities here Signing this document will allow FDACS Food Inspectors entry to my business during normal hours of operation for evaluation of facilities.
Form preview Nwcg interagency training nomi... NWCG INTERAGENCY TRAINING NOMINATION AND AGREEMENT TO COLLECT FUNDS INSTRUCTIONS: Complete Part I. Complete PART II only if there are tuition charges for the training. Part I - TRAINING NOMINATION
Form preview This operating agreement hipaa... HIPAA BUSINESS ASSOCIATE ADDENDUM This Business Associate Addendum ('Addendum') is a part of the Contract dated between the Department of and , contract number . For purposes of this Addendum,
Form preview Living quarters permit agreeme... Michigan.gov/lcc Business ID Request ID For MLCC use only Living Quarters Permit Agreement and Application Authorized by M. Complete form LCC-3619 Living Quarters Permit Agreement and Application 70. 00 Inspection fee Please submit with your signed application. The fees must be paid by check bank/postal money order made payable to State of Michigan/MLCC or by credit card using the attached Credit Card Authorization Form LC-3065.
Form preview Facility user account agreemen... FACILITY USER ACCOUNT AGREEMENT Please print clearly Section 1: Internet Data Submission (IDS) User Account Information (all information is required) 1. FACILITY NAME: 2. AHCA NUMBER: 3. NAME OF IDS
Form preview Sunadvantage pre authorized de... SunAdvantage Pre-authorized debit (PAD) agreement Category: Business TM To use PAD you must agree to all the terms of this authorization. By signing below as payor, you agree to the following: Sun
Form preview Wire transfer agreement form WIRE TRANSFER AGREEMENT Customer This agreement between the Bank named above and the Customer and its authorized agents hereafter Customer governs origination and receipt of wire transfers on behalf of the Customer. Customer s obligations shall not be excused in these circumstances. The Bank shall reject any transfer request or incoming wire transfer which does not conform to the limitations security procedures and/or other requirements set forth in this agreement such as availability of funds on deposit. 7 Rejection of the Bank s Transfer Request If the Bank receives notice that a wire transfer transmitted by the Bank has been rejected the Bank shall notify the Customer of such rejection including the reason given for rejection by telephone electronic message or U.S. mail. The Bank will have no further obligation to transmit the rejected wire transfer if it complied with this agreement with respect to the original transfer request. NOTE If Customer has enrolled in a service providing for submitting wire transfer requests online or electronically collectively Online Wire Requests then Customer will transmit transfer requests in accordance with the applicable Online Wire Requests service agreement and the security procedures for Online Wire Requests shall be Customer s access credentials and the submitter s actual access to the Online Wire Request system. If the Online Wire Request system is unavailable however then the option checked below will be used as backup for offline wire transfer requests. At the time the Bank executes a wire transfer or internal transfer the Customer agrees to pay the Bank with available funds on deposit for the amount of the wire plus the current Wire Transfer Fee as listed in the Bank s fee schedule. If the Customer fails to pay in accordance with this agreement the Bank shall be entitled to request cancellation of the transfer or to undertake any other legal means to collect the amount of the transfer if unable to cancel including exercise of right of offset as detailed in the Bank s Deposit Agreement. If the Customer fails to pay in accordance with this agreement the Bank shall be entitled to request cancellation of the transfer or to undertake any other legal means to collect the amount of the transfer if unable to cancel including exercise of right of offset as detailed in the Bank s Deposit Agreement. 6 Errors and Rejections by Bank If a wire transfer request indicates an intermediary bank or a beneficiary s bank inconsistently by name and identifying number execution of the request might be based solely upon the number even if the number identifies a bank different from the named bank or a person who is not a bank. Any termination shall not affect any obligations occurring prior to termination. 10 Authorization The Customer represents and warrants that the accounts listed below are owned entirely by the within-named Customer and are hereby authorized to be charged as instructed by the Customer for wire transfers and related fees The Customer hereby authorizes the following individuals as agents for purposes of authorizing wire transfer requests on behalf of the Customer. These agents shall remain authorized until the Customer notifies the Bank in writing of revocation of any agent s authorization. Other individuals can be authorized only by adding them to this agreement or by completion of a new agreement with the Bank. If Customer does not have a deposit account at Bank then Customer a hereby waives any right to a jury trial and agrees that any such claim or controversy shall be decided in a trial to a state or federal judge sitting without a jury in the state and county where Bank is headquartered or in the county of the physical Bank branch at which Customer requested the transfer and b hereby waives the right to litigate such claim or controversy in a class action as a class member or class representative. This agreement supersedes any prior agreements between the Bank and the Customer on the subject matter hereof and shall also be binding upon the Customer s heirs representatives and successors. In the event of any inconsistency between this agreement and the Deposit Agreement with respect to wire transfers this agreement shall govern. If any part of this agreement is invalid illegal or unenforceable the remaining provisions shall remain in effect.

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