PLEASE CHECK APPROPRIATE BOX Sample Clauses

PLEASE CHECK APPROPRIATE BOX. D We are an Out-of Parish Family D We are a Registered Parishioner at the following Parish _ _ _ Parish location ____ (subject to approval from that Parish) D We are Parishioners of Our Lady of Peace To receive a Parishioner Discount I agree to the following: • We will attend Mass at Our Lady of Peace on Sundays and Holy Days of Obligation. • I will use parish envelopes, at least 32 envelopes MUST be placed in the Offertory collection basket during attendance at Mass. The amount of our weekly contribution is a matter of justice to the parish and personal conscience, and we recognize this and attempt to donate in appropriate weekly amount. I understand that envelopes given in "batches" are not acceptable and violates both the letter and the spirit of this agreement. • I understand and agree that failure to observe this Parishioner Agreement will result in an assessment that will amount to the difference between the In-Parish tuition rate and the Out_-of-Parish tuition rate.

PLEASE CHECK APPROPRIATE BOX. Child Welfare Agency Employer Individual I would like to pick up my results in county Volunteer Agency Law-Enforcement/Dept of Corrections Out-of-State Adoption and ▇▇▇▇▇▇ Home Screening Prosecuting Attorney/Court (please provide docket number if available) MI Other Contractual employer

PLEASE CHECK APPROPRIATE BOX. ❑ Employee ❑ Volunteer

PLEASE CHECK APPROPRIATE BOX. New EFT account Change bank account on Change contact name, phone number or email address CONTACT NAME: For Office Use – CODE NAME ON BROOKSTON ENERGY ACCOUNT (Individual, Company, Trust) CONTACT PHONE NUMBER EMAIL ADDRESS (REQUIRED) SECOND CONTACT PHONE NUMBER Brookston Energy, Inc. is hereby requesting authority for the above-named individual/entity to initiate ACH credit transactions to the below-named bank account. This ACH authorization is valid from the effective date hereof until such time as this authorization is terminated in writing by the undersigned. The person whose name appears below indemnifies and ▇▇▇▇▇▇ holds harmless the named financial institution of any and all claims made or asserted by either party hereto. This authorization may be assigned in whole to a third party without notice to any party to this agreement. The above also agrees to comply with the National Automated Clearing House Association (NACHA) rules. FINANCIAL INSTITUTION TYPE OF ACCOUNT CHECKING SAVINGS MONEY MARKET NAME ON ACCOUNT FINANCIAL INSTITUTION ADDRESS CITY STATE ZIP BANK ACCOUNT NUMBER (NOT TO EXCEED 17 DIGITS) ROUTING NUMBER (REQUIRES 9 DIGITS) AUTHORIZED SIGNATURE TITLE DATE AUTHORIZED CO-SIGNATURE (Second signature required for JTWROS or TIC) TITLE DATE Please type or print clearly, attach a voided check, sign and return in the enclosed envelope within ten days from the date received. Make a copy for your records. The example of a voided check, shown below, indicates where to locate the routing number for your bank and your bank account number.

PLEASE CHECK APPROPRIATE BOX. C.R.S. § ▇▇-▇▇-▇▇▇ Employment-Certificate required

PLEASE CHECK APPROPRIATE BOX. C.R.S. §22-9-106 Local Board of Education, Duties, Performance Evaluation System Yes

PLEASE CHECK APPROPRIATE BOX. C.R.S. §▇▇-▇▇-▇▇▇ Teacher Employment, Compensation and Dismissal Act- Yes C.R.S. §▇▇-▇▇-▇▇▇ C.R.S. § ▇▇-▇▇-▇▇▇

PLEASE CHECK APPROPRIATE BOX. (Contact Name) (Title)

PLEASE CHECK APPROPRIATE BOX. I certify, pursuant to Public Law 2012, c. 25, that neither the bidder listed above nor any of the bidder’s parents, subsidiaries, or affiliates is listed on the New Jersey Department of Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 (“Chapter 25 List”). I further certify that I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. □ I am unable to certify as indicated above because the bidder and/or one or more of its parents, subsidiaries, or affiliates is listed on the New Jersey Department of Treasury’s list of entities determined to be engaged in prohibited activities in Iran. I will provide a detailed, accurate and precise description of the activities in Part 2 below and sign and complete the Certification below. Failure to provide the information required in Part 2 will result in the proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law.