MUST BE COMPLETED Sample Clauses

MUST BE COMPLETED. Enter the mailing address if it is different from the legal address in line 8.

MUST BE COMPLETED. Print Legal Name of Advertiser ____________________________________________________________ __________________________________________________________ ____________________________________________________________ By:_________________________________________________________ Phone #: By: • Images: Images should have an effective resolution of 300 dpi. 72 dpi images, or images downloaded from a website, are of unacceptable quality for magazine printing. Use or scale your images as close to the actual reproduction size as possible; a 20% margin plus or minus is optimal. ❒ Will participate in Parade ❒ Will not participate in Parade

MUST BE COMPLETED. Work assignments involve 20 hours per week (50 percent appointment) or 10 hours per week (25 percent appointment) as defined by immediate supervisor; or serving as the instructor of record for a maximum of two 3-hour courses. Additional work may be done by the student for his/her own research:

MUST BE COMPLETED. Emergency Contact Relationship Phone

MUST BE COMPLETED. If to the Contractor*: If to the Institution*: a t e w a y C o m m u n i t y C o l l e g e 2 h u r c h S t r e e t ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ t t n : D e a n M a r k ▇▇▇▇▇▇▇▇, PH.D New Haven Public Schools ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Attn: ▇▇. ▇▇▇▇▇ ▇▇▇▇▇▇

MUST BE COMPLETED. ▇▇▇ ▇▇▇ ▇▇▇ ▇▇▇ ▇▇▇ ▇▇▇ 1. Provider’s daily rate. $ $ 2. Meals: Enter daily cost (If cost of meal is included in the Provider’s Daily Rate on line 1, enter 0). $ $ 3. Transportation: Enter daily cost (If cost of transportation is included in the Provider’s Daily Rate on line 1, enter 0). $ $ 4. Add lines 1, 2, & 3, enter amount. TOTALS ARE THE PROVIDER’S PROJECTED DAILY CHILD CARE CHARGES. $ $ 5. Enter amount DES will subsidize the provider (See CC-214, Child Care Provider Rate Agreement). $ $ 6. Enter amount of Parent/Guardian’s daily DES Assigned Copaymant (See Certificate of Authorization). $ $ 7. Subtract line 6 from line 5 and enter amount. THIS IS THE DAILY RATE DES WILL REIMBURSE THE PROVIDER. $ $ 8. Subtract line 7 from line 4 and enter amount. THIS IS THE DAILY AMOUNT OF THE PROVIDER RATE NOT SUBSIDIZED BY DES, AND THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO REIMBURSE THE PROVIDER. $ $ DESCRIPTION FREQUENCY OF PAYMENT AMOUNT OF PAYMENT Registration Fees: $ Other (Specify): $ Other (Specify): $ 1st Child 3rd Child 2nd Child As the parent/guardian of the child(ren) in care, I agree to accept responsibility for the payment of the DES Assigned Full/Part Day Copayment on line 6, the Full/Part Day Charges listed on line 8 or any “Additional Fees.” PARENT/GUARDIAN’S SIGNATURE DATE As the provider, I understand that the DES will not monitor the parent/guardian’s payment for charges that exceed the Full/Part Day Charges on line 7, the Full/Part Day Charges listed on line 8 or any “Additional Fees.” CHILD CARE PROVIDER’S SIGNATURE DATE DISTRIBUTION: Original (white) - for provider; Copy (canary) – for parent/guardian CC-208 (5-11) – Page 47 Arizona Department of Economic Security Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (▇▇▇▇) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair...

MUST BE COMPLETED. ❑ The UAFS courses I am taking will count toward ❑ The UAFS courses I am taking will NOT my high school graduation and college credit. count toward my high school graduation. High School Principal’s Signature Date (or authorized designee) Parent’s signature Student’s Signature Return completed original of this form, completed application for admission, latest high school transcript, and placement scores to: Admissions and School Relations Office University of Arkansas - Fort ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ P.O. Box 3649 Fort ▇▇▇▇▇, AR 72913-3649 Rev. 08-26-14

MUST BE COMPLETED. Enter name, telephone number and email of owner, partner or company employee who will be the contact person.

MUST BE COMPLETED. 1st 2nd 3rd 1st 2nd 3rd 1. Provider’s daily rate. $ $ $ $ $ $ 2. Meals: Enter daily cost (If cost of meal is included in the Provider’s Daily Rate on line 1, enter 0). $ $ $ $ $ $ 3. Transportation: Enter daily cost (If cost of transportation is included in the Provider’s Daily Rate on line 1, enter 0). $ $ $ $ $ $ 4. Add lines 1, 2, & 3, enter amount. TOTALS ARE THE PROVIDER’S PROJECTED DAILY CHILD CARE CHARGES AND THE RESPONISBILITY OF THE PARENT/ GUARDIAN TO REIMBURSE THE PROVIDER. $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00