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Motor america sales form APPLICATION FOR HYUNDAI MOTOR AMERICA SALES SERVICE AGREEMENT Hyundai Motor America 10550 Talbert Ave. P. O. Box 20850 Fountain Valley California 92728-0850 U*S*A. Telephone 714 965-3000 Date The following information is submitted in support of this application for a Hyundai Dealer Sales Service Agreement. I understand that you receipt of this submission does not constitute acceptance or approval of the applicant. NAME IN FULL First Middle Last HOME ADDRESS Street City State Zip Code BUSINESS NAME AND ADDRESS Street City State Zip Code PRESENT OCCUPATION BUSINESS TELEPHONE NO. HOME TELEPHONE NO. CURRENT AND PREVIOUS BUSINESS EXPERIENCE Do you now own operate or have a financial interest in or have you previously owned operated or had a financial interest in any automobile dealership yes No If yes please complete the information requested below on all franchises in which you have any ownership NAME OF MAKE S HANDLED NAME OF DEALERSHIPS FINANCIAL INTEREST PERIOD FROM TO CITY COUNTY STATE REASON FOR TERMINATING Attach an extra page if necessary. Outline in chronological order the positions or businesses in which you have participated 10 years minimum most recent first. ADDRESS Street City State Zip Code NAME OF COMPANY TYPE OF BUSINESS IF AUTOMOTIVE RETAIL WHOLESALE MANUFACTURING LAST POSITION ANNUAL SALARY IMMEDIATE SUPERVISOR REASON FOR LEAVING PERSONAL DATA MARITAL STATUS BIRTHPLACE DATE OF BIRTH NUMBER OF DEPENDENT CHILDREN NUMBER OF OTHER DEPENDENTS SOCIAL SECURITY NO. CONDITION OF HEALTH DATE OF LAST MEDICAL EXAM MARRIED SINGLE EDUCATION TYPE OF SCHOOL NAME AND LOCATION OF SCHOOL DATES ATTENDED GRADUATED HIGH SCHOOL YES COLLEGE OR UNIVERSITY DEGREE NO BUSINESS OR TRADE SCHOOL OTHER TRAINING Have you ever failed in business or compromised with creditors Yes Have you ever been bonded Has your bond ever been withdrawn or application rejected Do you have any lawsuits pending against you Are you an endorser of any bills or notes mortgages bonds etc* of others Have you ever had a business or occupational license revoked suspended or subjected to other disciplinary action Please explain affirmative answers to the foregoing questions in detail attach extra page if necessary. BANK REFERENCES BANK AND/OR FINANCE COMPANY PRINCIPAL CONTACT NAME AND TITLE CITY STATE PERSONAL REFERENCES Do not list present or previous employers employees or relatives. NAME IN FULL OCCUPATION NO. OF YEARS KNOWN YEARS OF BANKING RELATIONSHIP CURRENT DEALERSHIP INFORMATION If you are currently in business as an automobile dealer please complete this section for each of your dealerships use additional sheets if necessary List sales for each make separately RETAIL USED CAR SALES UNITS MAKE S Current Last Year 2 Years CUSTOMER SATISFACTION INDEX DEALER AVERAGE ZONE/REGION NATIONAL PROPOSED DEALERSHIP INFORMATION Indicate up to three locations of interest for a single line Hyundai dealership* GENERAL LOCATION WITHIN CITY COUNTY STATE Briefly describe your automobile experience in management new and used automobile sales parts and service and why you feel you are qualified to own and/or operate a Hyundai dealership* How much money are you prepared to invest in the proposed dealership If your investment requires liquidation of certain assets listed on your attached Personal Financial Statement which assets would be used how are they to be liquidated and when would the proceeds be available For the purpose of securing credit and other considerations the undersigned furnishes the above information and Financial Statements which fully and truly set forth the applicant s financial condition on the day of 20.

Form for respondant to divorce... DIVORCE - WITH MINOR CHILDREN For Respondent Only Response Part 3 Respond to a Divorce Petition Forms Packet Superior Court of Arizona in Maricopa County Packet Last Revised December 2008 ALL RIGHTS RESERVED DRDC3fc - 5022 SELF-SERVICE CENTER DISSOLUTION OF A NON-COVENANT MARRIAGE DIVORCE WITH MINOR CHILDREN FOR RESPONDENT ONLY PART 3 -- RESPONSE TO A PETITION This packet contains court forms about how to respond to a Petition for Dissolution of a NonCovenant Marriage Divorce With Minor Children. The documents should appear in the following order Order File Number pages Title DRDC3ft Table of forms in this packet DRDC3k Checklist You may use these forms if. DRSDS10f Sensitive Data Sheet DRAD10f Alternative Dispute Resolution ADR Statement to the Court The documents you have received are copyrighted by the Superior Court of Arizona in Maricopa County. You have permission to use them for any lawful purpose. These forms shall not be used to engage in the unauthorized practice of law. The Court assumes no responsibility and accepts no liability for actions taken by users of these documents including reliance on their contents. The documents are under continual revision and are current only for the day they were received* It is strongly recommended that you verify on a regular basis that you have the most current documents. April 15 2008 Page 1 of 1 Use most current version RESPONSE TO PETITION AND PAPERS FOR DISSOLUTION OF A NON-COVENANT MARRIAGE DIVORCE CHECKLIST Use the forms and instructions in this packet ONLY if the following factors apply to your situation You want to file a Response to a Petition for Dissolution of a NonCovenant Marriage Divorce With Minor Children AND You and your spouse have minor children with each other OR the wife is pregnant by the husband or will be pregnant by the husband before the divorce is over. READ ME Consulting a lawyer before filing documents with the court may help prevent unexpected results. The Self-Service Center has a list of lawyers who can give you legal advice and who can help you on a task-by-task basis for a fee and a list of court-approved mediators as well* You may view the lists at the Self-Service Centers or on the Internet at www. superiorcourt. maricopa*gov/SuperiorCourt/Self-ServiceCenter/LawyersAndMediators/. December 18 2007 Use only most current version. Name Representing Self Petitioner Respondent If Attorney State Bar Number SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY FOR CLERK S USE ONLY Case No* ATLAS No* SENSITIVE DATA SHEET Not public record Fill out. File with Clerk of Court. Omit Social Security Numbers when requested on other forms. Do NOT serve this document on the other party. A. Personal Information Male or Gender Female Date of Birth Month/Day/Year Social Security Number Driver s License Number Mailing Address City State Zip Code Daytime Phone Evening Phone Other Phone cell/pager Email Address Current Employer Name Employer Address Employer City State Zip Code Employer Telephone Number Employer Fax Number B.

12285 mandatory disclosures fa... RULE 12.285. (a) MANDATORY DISCLOSURE Application. (1) Scope. This rule shall apply to all proceedings within the scope of these rules except proceedings involving adoption, simplified dissolution,

Dead endangered species applic... DES NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DIVISION OF FISH, WILDLIFE AND MARINE RESOURCES - SPECIAL LICENSES 625 BROADWAY, ALBANY, NEW YORK 12233-4752 APPLICATION FOR A PERMIT TO

Form school order Maryland State Management of Diabetes at School/Order Form This order is valid only for the Current School Year including summer session Student DOB School Grade CONTACT INFORMATION Parent/Guardian Home Phone Work Cell/pager Other Emergency Contact Orders complete only if is needed at school 1. With student With teacher If most recent blood glucose is less than exercise can occur when blood glucose is corrected and above. Eat grams of carbohydrate Before Every 30 mins during After vigorous exercise Avoid exercise when blood glucose is greater than or ketones are Bus Transportation Check blood glucose 15 minutes prior to boarding bus Allow student to eat on bus if having symptoms of low blood glucose Provide care as follows Student can self-perform the following procedures school nurse and parent must verify competency Measuring Injecting Determining dose Independently operating pump Disaster Plan if needed for lockdown 24 hr shelter in place Follow orders as on Management Form Additional orders as follows Administer long acting as follows Other instructions Parent s Signature Pump Resource Person Phone Pump Management Type of pump Start Date for Pump Therapy Type of in pump 12am to /carbohydrate ratio Hyperglycemia Comment Check Management of Diabetes at School Order or correction factor Pump site should be changed if BG greater than times should be given by syringe or pen if needed Management Skills of Student As verified by school nurse health care provider and parent Count carbohydrates yes no Bolus an dose Reset basal rate profiles Set a temporary basal rate Disconnect pump Reconnect pump at infusion set Prepare infusion set for insertion Insert infusion set Troubleshoot alarms and malfunctions Give self injection if needed Change batteries Student is non-independent Child Lock On Yes No Pump Supplies Extra supplies needed include Infusion sets reservoir/cartridges insertion device vial syringes batteries Location of supplies doses as follows MSDE8/10. administration via Syringe and vial pen pump Other Type of pump Basal rates 2. Before Lunch/Meals Name of Routine lunchtime dose Per sliding scale as follows Meals Blood Glucose to give units Calculated dose add carbohydrate coverage and correction dose for total dose Carbohydrate Coverage to carbohydrate ratio Give unit s pergms carbohydrate. Correction Subtract units for every mg/dl of glucose below mg/dl may be given after lunch if 3. Other times may be given Calculated as above. Snack Dose Ketones If ketones are Give/Add unit s Give Health Care Provider Authorization for Management of Diabetes in School My signature below provides authorization for the above written orders. This authorization is for a maximum of one school year. If changes are indicated I will provide new written authorization which may be faxed* Address City Zip Phone Fax Use for Prescriber s Address Stamp Parent Consent for Management of Diabetes at School I We request designated school personnel to administer the medication and treatment orders as prescribed above.

Standard authorization form bc... HCSC Instructions for Completing BlueCross BlueShield of Texas Standard Authorization Form To Complete Form go to Page 4 of 5 Under the HIPAA Privacy Rule, an individual may authorize the release

Alpha chi omega recommendation... Form A/C 62 Please attach photo if possible. LEGACY Yes No ALPHA CHI OMEGA RECRUITMENT INFORMATION (Please complete with as much information as possible or attach r sum .) Potential Member's Name

Randall county judicial enforc... RANDALL COUNTY JUDICIAL ENFORCEMENT DEPARTMENT COURT COLLECTIONS APPLICATION FOR EXTENSION OF TIME TO PAY HOW MUCH ARE YOU PAYING TODAY? PERSONAL INFORMATION - COMPLETE ALL BLANKS Office Use Only

Standard physical form O.K. Conference Pre-Participation Physical Exam Form Medical Examination THIS SIDE TO BE COMPLETED BY EXAMINING MEDICAL PROFESSIONAL Name: Date: Ht: Wt: HR: BP: BP reck: Corrective Lenses: Y or N

Aviva foundation form Aviva Charitable Foundation Grant Application www. avivausa.com 7700 Mills Civic Parkway West Des Moines IA 50266-3862 INSTRUCTIONS 1. 8. Are you affiliated with any other local or national agencies please list 9. Have you previously received support from Aviva Charitable Foundation If no state. Annotated board of directors list. Submit completed Application and Attachments to Karen Lynn Aviva Charitable Foundation Mailing Address Email AvivaFoundation avivausa.com. Do not delete or alter any selection* 2. Do not change the order of the information* 3. Information required is shown in yellow boxes do not alter text in yellow boxes. 4. Provide your organization s information in white boxes. 5. Attach additional sheets if necessary. 6. It is not necessary to print and submit your Application in color. BACKGROUND Date of Grant Request Organization Name Federal Tax Identification Number Address City State Zip Code Contact Person Title Email Address Phone Type of support requested Requested amount Program category Program Grant Operating Expenses Arts Culture Civic Community Education Is your organization a member of the United Way targeted market areas Des Moines IA Topeka KS Melville NY 17935 Yes Street to School Health Human Services No If no the grant request is probably not eligible for funding ver. 8/12 Page 1 of 4 REQUEST statement. 2. Describe the project/program for which support is requested* 3. Dates and length of project/program* 4. Assets your organization possesses that enhance the 5. Describe the goals of the program for which support is requested* 6. Describe how this program will be evaluated* 7. Describe the clients and geographical area your program serves. If yes please describe and state date of funding. 10. Are Aviva employees active participants and/or volunteers in yes please list their names. 11. Why should Aviva provide support for this request ver. 8/12 Page 2 of 4 BUDGET Total Program Total Organization 13a* Current fiscal-year budget Expenses Income Fund Balance 13b. Last fiscal-year budget 14. Total annual revenue from your last fiscal year 15. List your three largest contributors name / amount 16. Sources of Income Corporations Government Individuals Programs How much is spent in this community To national organization 19. Is your organization carrying a deficit If no please list amount of current operating reserve or endowment. If yes please describe. 20. Identify additional sources of support that are or will be available for the balance of the program budget. of budget Fees Services Interest income Benefits/Special Events Other Total Operating Ratios Administration Fund-raising of total No OTHER 21. Other information that is helpful in reviewing your application* ATTACHMENTS Please attach the following documents to this application IRS 501 c 3 determination letter. Do not delete or alter any selection* 2. Do not change the order of the information* 3. Information required is shown in yellow boxes do not alter text in yellow boxes. 4. Provide your organization s information in white boxes. 5. Attach additional sheets if necessary.

Minnesota standard consent for... Minnesota Standard Consent Form to Release Health Information Complete Sections 1 3 and 9. Sections 2 6 8 are Optional Patient Information First name Middle name Last name Patient date of birth // Previous name s Home address City State Zip code Daytime phone E-mail address optional Medical Record/patient ID number optional Contact for information about how this form was filled out optional I give permission for the organization s listed in secti...

Standard form apartment lease... G R E A T B O S N L D STANDARD FORM APARTMENT LEASE SIMPLIFIED FIXED TERM Date This is a Lease of Apartment No. Located in a Building Numbered in Massachusetts. The Landlord is whose address is SA M PL The term of this lease is beginning on and ending on Landlord and Tenant agree that each of them has various rights and duties and that this Lease is subject to certain conditions as follows FOR MAINTENANCE THE TENANT SHOULD CONTACT Name Telephone Street Address City State Zip To be filled in only where maintenance is performed by Managing Agent. TENANT This section governs rent payments. In some cases rent payments may increase during the lease term* Please be sure that you carefully read and understand this section* Please initial here when you are certain that you understand and agree with this section* payments. Be sure to discuss with the Landlord those payments which will be required of you for this Apartment 1. RENT a On or before the first day of every month in advance the Tenant must pay the monthly rent which is. the Building as well as the land on which it is located* Real estate taxes are assessed on a fiscal year basis and each fiscal year begins on July 1 and ends on the following June 30. The most recent tax bill received by the Landlord was for the fiscal year ending June 30 but real estate taxes may be higher in later fiscal years. If this happens the Tenant will be required to pay of the increase. This payment which is considered additional rent will be prorated if this Lease is not in effect throughout the entire fiscal year in which the tax increase occurs. The Landlord will notify the Tenant of any tax increase and will explain how the Tenant s share is to be paid* The Tenant s share of any tax increase must always be in proportion to the relationship between 1 the apartment and 2 the whole of the real estate being taxed namely the Building and the land on which it is located* If the Landlord obtains an abatement or refund of the real estate tax levied on the whole of the real estate a proportionate share of the abatement or refund less reasonable attorney s fees if any must be refunded to the Tenant. 2. HEAT AND UTILITIES Landlord will furnish all required heat hot water fuel oil and utilities to the Apartment with the following exceptions. First the Tenant must make all service arrangements and pay all bills for telephone as well as gas electricity and water and sewer service if checked* Gas or electricity should be checked only if the Tenant s usage is measured by a separate meter which has already been installed in which case it will also be the Tenant s responsibility to make all necessary service arrangements. Water and sewer service should be checked only if a the Tenant s usage is measured by a separate meter or submeter which has already been installed and b a Water and Sewer Submetering Addendum has been signed by make all necessary service arrangements and pay all bills for fuel oil which is provided through a separate oil tank and used to supply heat and/or hot water only to the Apartment.

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