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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 Commercial lease agreement tem... Commercial Lease Application Form Address of Premises: Applicants: Company/Business/Personal Name: Business Phone: Registered Address: Proposed Use: Premises Currently Leased or Owned: LEASED/OWNED
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 Iowa public health supervision... PUBLIC HEALTH SUPERVISION AGREEMENT Agreement Between: Supervising Dentist's Name: Work Address: Work Phone: E-mail: Dental Hygienist's Name: Work Address: Work Phone: E-mail: Years of Clinical Practice
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 Miscellaneous lien amendmentte... NORTH DAKOTA SECRETARY OF STATE/REGISTERS OF DEEDS SFN 52084 (7-99) MISCELLANEOUS LIEN AMENDMENT/TERMINATION MSL-2 PLEASE TYPE. Please read instructions on back before completing. A. Filing Fee Instructions
Form preview Authorization agreement to the... TELEPHONE Complete Section C and remit authorization agreement to the RI Division of Taxation EFT Section. If ACH Debit is chosen you authorize the Rhode Island Division of Taxation to present debit entries to your bank for the tax identified on the front.

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