Multiple Scheduling Coordinator Form Maryland and District of Columbia
|
|
- Philip Shanon Ferguson
- 7 years ago
- Views:
Transcription
1 Multiple Form Maryland and District of Columbia In order to register a multiple scheduling coordinator, you must already be a registered supplier in Pepco. Please send the completed executed form to: Pepco Supplier Relations 701 Ninth St N.W., Rm Washington, DC Company Information Legal Business Street Address: City, State, Zip Code: Trading as name if different: Federal ID NO: Licensing Data MD License Number: Date of License: DC License Number: Date of License: and DC Page 1 of 8
2 Banking Information (W9 required) Bank Address: Contact at the Bank: Name on Account: ABA Routing: Account Number: Supplier s Contact Information (Printed on Pepco s Consolidated Bill) Telephone Number: Address: Mailing Address: Supplier s Short Name (10 characters used for labels): Multiple (If registering more than 1 MSC, please fill out page 5) Is there a separate entity that has been appointed as the scheduling coordinator? If yes, provide the Page 2 of 8
3 Certification Applicant hereby warrants and represents that all statements and representations made herein, and on any supporting documents, are true and correct. The undersigned hereby certifies that he/she is authorized to sign this application on behalf of applicant, and that applicant agrees to be bound by all statements and representatives contained in this Supplier Registration form. Authorized officials of the Applicant warrants that the Applicant agrees to be bound by this representation: Submitted By: Applicant s Company Signature of Authorized Official: Name of Authorized Official: Title of Authorized Official: Date Signed: Page 3 of 8
4 Contact Information (Update all appropriate contacts) Main Contact Title: Address: EDI Contact Title: Address: Invoicing & Accounting Contact Title: Address Billing Contact: Title: Address: Page 4 of 8
5 Multiple s and DC and DC Page 5 of 8
6 and DC and DC Page 6 of 8
7 and DC and DC Page 7 of 8
8 and DC and DC Page 8 of 8
Welcome to FLCLASS. Thank you for choosing FLCLASS! Sincerely, The FLCLASS Board of Trustees. 4767 New Broad Street Orlando, FL 32814
Welcome to FLCLASS We believe you have made a sound financial decision in choosing Florida Cooperative Liquid Assets Securities System (FLCLASS). We look forward to being your trusted provider and are
More informationELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT THIS ELECTRONIC DATA INTERCHANGE TRADING PARTNER AGREEMENT
ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT THIS ELECTRONIC DATA INTERCHANGE TRADING PARTNER AGREEMENT (the Agreement ) is made as of, by and between Potomac Electric Power Company (Pepco),
More informationCommercial Electricity and Natural Gas Supply Services Cooperative Program Application
Commercial Electricity and Natural Gas Supply Services Cooperative Program Application Customer Location: AUTHORIZATION TO OBTAIN BILLING, PAYMENT HISTORY, ACCOUNT SERVICE DATA, AND CREDIT DATA Legal Customer
More informationElectricity and Natural Gas Supply Services AUTHORIZATION & APPLICATION FORM
Electricity and Natural Gas Supply Services AUTHORIZATION & APPLICATION FORM ELECTRIC AND NATURAL GAS BILLING, PAYMENT HISTORY, ACCOUNT SERVICE DATA, AND CREDIT DATA SUPPIER AUTHORIZATION Customer Location:
More informationCREDIT DATA TRADE REFERENCES: Name Address Phone # Fax # 1. 2. 3. 4.
CUSTOMER PROFILE AND CREDIT APPLICATION 4143 County Rd 61 Phone 260-868-2645 Butler, IN 46721 Fax 260-868-2369 In order for Magic Coil Products, LLC to set up an account for you and approve a credit line,
More informationHORSEMAN S SIGNATURE CARD FOR INCOMPASS FINANCIAL SERVICES FUNDS TRANSFER MODULE AGREEMENT
HORSEMAN S SIGNATURE CARD FOR INCOMPASS FINANCIAL SERVICES FUNDS TRANSFER MODULE AGREEMENT By signing below, each of the undersigned Horsemen agree to be bound by the terms and conditions, and to make
More informationSECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS. Select if this is a new application, change of submitter, update.
Notification Secure EDI provides this agreement as a courtesy for our customers. We make every effort to keep these forms updated however; the payer may not always notify us when changes have been made
More informationSECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K
SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT PURSUANT TO SECTION 13 or 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 Date of Report: February 18, 2004 HUNTINGTON BANCSHARES
More informationHow To Get Paid Fast
Dear Schneider Carrier Network Member, As a transportation leader, Schneider understands the pressures today's carriers face from rising fuel and insurance costs to a cash flow squeeze when shippers take
More informationDelaware 000-50703 14-1839426 (State or other jurisdiction of incorporation)
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 Date of Report: April 16, 2014 (Date
More informationOnce your account is established, you will receive a confirmation email or fax with your account number and an order form.
Welcome to sanofi-aventis U.S. LLC and Genzyme Corporation. This new account welcome kit provides you with essential information on how to request a new account and understand our standard business policies
More informationTHE NASDAQ STOCK MARKET
THE NASDAQ STOCK MARKET Waive-In Membership Application Form To qualify for Waive-In Membership in The NASDAQ Stock Market LLC (NASDAQ), the applicant must be an approved National Association of Securities
More informationInstitutional Bank Transfer Form
Institutional Bank Transfer Form Please print clearly in capital letters and black ink. This form is to be used to add U.S. bank account instructions to a Vanguard account(s) and should only be used by
More informationAs always, we welcome cash and credit card customers for all purchases.
Corporate Credit Department 12802 Commodity Place Tampa, FL 33626 Phone: 813-792-3663 813-792-3661 Fax: 813-434-2347 email:ar2@qssi.com Credit Application Dear Customer: Thank you for applying for credit
More informationHow To Get A Transporter Tag In Martha Michael
CS-050 (12-13) Instructions for Interchangeable Registration Plates for Transporters and Finance Companies All CS forms listed on this sheet should be included in this licensing package. Please call (410)
More information**Incomplete vendor registration submissions will be discarded after 30 days.**
**Incomplete vendor registration submissions will be discarded after 30 days.** Procurement Services Department 130 Trinity Avenue, 4 th Floor Atlanta, GA 30303 Fax (404) 802-1506 Vendor Registration Form
More informationCredit Application for a Business Account
Credit Application for a Business Account Jackson Plant: Ohio Basic Minerals LLC Corporate Office: Ohio Basic Minerals LLC 15317 Beaver Pike Road 1700 Broadway Suite 1170 Jackson, OH 45640 Denver, CO 80290
More informationUNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 Date of Report (Date of earliest event
More informationDEBT SETTLEMENT PLAN (Only Committees that are terminating are eligible to file this form.) (See reverse side for instructions)
FOR OCF USE ONLY GOVERNMENT OF DISTRICT OF COLUMBIA OFFICE OF CAMPAIGN FINANCE WASHINGTON, D.C. 20009 ID# NAME OF DEBT SETTLEMENT PLAN (Only Committees that are terminating are eligible to file this form.)
More informationOn Line Banking Agreement and Application for Commercial Accounts
On Line Banking Agreement and Application for Commercial Accounts You must be an existing Business Account holder of the Belt Valley Bank, hereinafter referred to as Bank, in order to apply for the On
More informationCredit Application/Agreement. Company Name: Check one: Corporation Partnership Sole Proprietorship Limited Liability Co.
En-Net Services, LLC Phone: 301-846-9901 Fax: 301-846-9902 712 N East Street Frederick, MD 21701 Internet: www.en-netservices.com Email: administration@en-netservices.com Credit Application/Agreement Company
More informationCustomer: Thank you again for your patronage. We look forward to serving your needs. Sincerely, S. T. Wooten Corporation
Customer: Thank you for choosing to do business with S. T. Wooten Corporation. We are committed to providing you, our valued prospective or existing customer, with the highest level of satisfaction possible.
More informationBusiness Application & Policy Notice
Global Organic Specialty Source, Inc. 6284 McIntosh Rd, Sarasota, Fl. 34238 Phone (941) 358-6555 (941) 358-6551 Business Application & Policy Notice Date DBA Business Name State Registration # Federal
More informationBusiness Entities Authorized Signers and Traders Form
Business Entities Authorized Signers and Traders Form Complete this form to designate the individuals authorized to act on behalf of your corporation, partnership, or other organization (hereinafter referred
More informationDiscount Steel, Inc. 800-522-5950
Discount Steel, Inc. 800-522-5950 Corporate Division Fort Worth Division Hardware Division 216 27 th Ave. North 10353 Hicks Field Rd 2626 N. 2 nd St Minneapolis, MN 55411 Fort Worth, TX 76179 Minneapolis,
More information2012 Crash Course Teen Driving Summit Contest Statement of Eligibility
2012 Crash Course Teen Driving Summit Contest Statement of Eligibility All forms must be returned to Kathy Monroe, MD at kmonroe@peds.uab.edu or by fax: (205) 975-4623 by October 26, 2012 at 11:59 p.m.
More informationetsc Business Registration Application
Government of the District of Columbia Office of the Chief Financial Officer Office of Tax and Revenue Vincent C. Gray Mayor Natwar M. Gandhi Chief Financial Officer Stephen Cordi Deputy Chief Financial
More informationCalifornia Republic Auto Receivables Trust 2015-1 (Exact name of issuing entity as specified in its charter)
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 10D ASSETBACKED ISSUER DISTRIBUTION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 For the monthly
More informationCalifornia Republic Auto Receivables Trust 2015-2 (Exact name of issuing entity as specified in its charter)
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 10D ASSETBACKED ISSUER DISTRIBUTION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 For the monthly
More informationVerification of Professional Experience
Land Surveyor Form 4A The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Division of Professional Licensing Services www.op.nysed.gov Verification of Professional
More informationName of Student: (Please Print) Street Address: City: State: ZIP: Email Address: How did you hear about us?
CERTIFICATE PROGRAM ENROLLMENT FORM PARALEGAL INSTITUTE OF WASHINGTON, D.C. 5101 WISCONSIN AVE., NW SUITE 302, WASHINGTON, D.C. 20016 PHONE 202-955-4562 FAX 202-955-6069 Student Information Name of Student:
More informationUNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington D.C. 20549 CURRENT REPORT
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 OR 15(d) of the Securities Exchange Act of 1934 Date of report (Date of earliest event
More informationREQUIREMENTS FOR PRODUCER CODE
REQUIREMENTS FOR PRODUCER CODE Enclosed are the materials that will enable you to apply for a Maryland Automobile Insurance Fund/Maryland Auto Producer Code. These forms include: Application for Authority
More informationGULFPORT ENERGY CORPORATION
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities exchange act of 1934 Date of report (Date of earliest event
More informatione.service Merchant Services
e.service Merchant Services With Debit Card Filter for Pre-Bankruptcy Credit Counseling Payments 1) Return the following: APPLICATION INSTRUCTIONS PROGRAM CHARGES CREDIT APPLICATION INCLUDE COPY OF 501(c)(3)
More informationFEDERATED NATIONAL HOLDING COMPANY (Exact name of registrant as specified in its charter)
UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 Date of Report: January 9, 2014 (Date
More informationDocuments Required. $400 due diligence check per company made payable to Capstone Business Funding, LLC
Legal Business Name Date Documents Required Current Accounts Receivable Aging Report Company Information Application and Origination Statement (Have your signature notarized under Origination Statement
More informationDC DMV WEBSITE ACCESS REQUEST AND APPROVAL
DC DMV WEBSITE ACCESS REQUEST AND APPROVAL Insurance companies who choose to report via District Of Columbia Department of Motor Vehicles (DC DMV) website must request a Company ID, User ID and Password.
More informationGENERAL REGISTRATION APPLICATION - BUSINESS INFORMATION
GENERAL REGISTRATION APPLICATION - BUSINESS INFORMATION ENCLOSURES REQUIRED WITH THIS FORM a) Evidence of business status (i.e., Articles of Incorporation, Certificate of Limited Partnership, Articles
More informationSECURE EDI ENROLLMENT AGREEMENT INSTRUCTIONS
Notification Secure EDI provides this agreement as a courtesy for our customers. We make every effort to keep these forms updated however; the payer may not always notify us when changes have been made
More informationSchool ID/ Certificate Number SED CODE
New York State Education Department Bureau of Proprietary School Supervision Applicant Instructions Application for Transfer of a Certification to Operate an ESL School in New York State BPSS-4 For Office
More informationBuilder/Retailer Approval Checklist
Builder/Retailer Approval Checklist Builder/Retailer must be approved by prior to loan closing. Builder/Retailer: Builder/Retailer Summary Application Contractor's Performance Agreement Disbursement Instructions
More informationFEDERATED NATIONAL HOLDING COMPANY (Exact name of registrant as specified in its charter)
UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 Date of Report: July 15, 2015 (Date
More informationNon Exchange Trading Broker Agreement
Clearing Agreement F to the Commodity Derivatives Clearing Rules Appendix 10 to the Clearing Rules of NASDAQ OMX Derivatives Markets Non Exchange Trading Broker Agreement Non Exchange Trading Broker: [insert
More informationCLIENT INFORMATION FORM
Please take a moment to complete this form. We will consider it, along with your group s experience, enrollment data, and any other applicable information, when setting up your account with Delta Dental.
More informationBY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY )
BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY ) NOTICE: PLEASE ANSWER ALL OF THE FOLLOWING INQUIRIES.
More informationCredit Application Terms
Dundee Manufacturing 107 Fairchild Drive Dundee, MI 48131 P: 734.529.2540 F: 734.529.3583 Credit Application Terms New Accounts To open a new credit account with Dundee Manufacturing please fill out the
More informationDo not alter the submitter information on Page 2. Do not alter or add any transactions on the top of Page 3. MD On-Line ATTN: Enrollment
DELAWARE MEDICAID EDI CONTRACT INSTRUCTIONS (SDKE0) Please MAIL all pages of your completed and signed forms to: MD On-Line ATTN: Enrollment 6 Century Dr 2 nd Fl Parsippany NJ 07054 Do not submit forms
More information6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details:
Name of Insurance Company to which Application is made (herein called the Insurer ) CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR DEFENSE COSTS, ADMINISTRATIVE EXPENSES, NOTIFICATION COSTS,
More informationDIRECTV HOLDINGS LLC
DIRECTV HOLDINGS LLC FORM 8-A12B (Securities Registration (section 12(b))) Filed 11/21/13 Address 2260 E. IMPERIAL HIGHWAY EL SEGUNDO, CA 90245 Telephone 310-964-0724 CIK 0001234308 SIC Code 4841 - Cable
More informationGOVERNMENT & PUBLIC ORGANIZATIONS, MAJOR CORPORATE MEMBERSHIP SMALL BUSINESS, AND NONPROFIT PROGRAM MEMBERSHIP PROGRAM PURSUE WIN EXECUTE
2014 GOVERNMENT & PUBLIC ORGANIZATIONS, MAJOR CORPORATE MEMBERSHIP SMALL BUSINESS, AND NONPROFIT PROGRAM PURSUE WIN EXECUTE 2014 GOVERNMENT & PUBLIC ORGANIZATIONS, SMALL BUSINESS, AND NONPROFIT Partnering
More informationNAMWOLF Law Firm Membership Application
NAMWOLF Law Firm Membership Application The National Association of Minority & Women Owned Law Firm s (NAMWOLF s) goal is to have a blend of minority and women owned law firms, dispersed across the United
More informationDrug Other Controlled Substance Registration Application Packet. In order to process your request: Contents:
Pharmacy Board P.O. Box 47877 Olympia WA 98504-7877 Drug Other Controlled Substance Registration Application Packet Contents: 1. 690-159...Application Packet Index Page...1 Page 2. 690-160... Drug Other
More informationSetting up your Endicia Account.
Setting up your Endicia Account. This document covers signing up for an Endicia Internet Postage account, and downloading and installing the DAZzle label printing program. First, go to the Endicia.com
More informationUNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K/A AMENDMENT #1
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K/A AMENDMENT #1 CURRENT REPORT Pursuant to Section 13 OR 15(d) of the Securities Exchange Act of 1934 Date of Report (Date
More informationCredit and Payment Policies
Credit and Payment Policies Credit Policies Registrars must have a RegistryPro Registrar Financial Information Form and a Registrar Data Form on file with the Registry. The Registrar s credit limit is
More informationPlease Print, Complete, Sign and Fax to Sandra Barnett at (251)471-2423
Credit Application Please Print, Complete, Sign and Fax to Sandra Barnett at (251)471-2423 The following is an application for credit with AL-FLA Plastics Co., also known as creditor within the general
More informationSFD Offer of Sale (Form B) Instructions 2
District of Columbia Department of Housing and Community Development Housing Regulation Administration Rental Conversion and Sale Division 1800 Martin Luther King, Jr. Avenue, S.E. Washington, DC 20020
More informationCORPORATE ACCOUNT. ...we make the difference
CORPORATE ACCOUNT CORPORATE ACCOUNT GUIDE TO OPENING YOUR ACCOUNT Please complete all the relevant portions of the Application Form and Account Opening mandate and return the package along with the following
More informationUNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 Date of Report (Date of earliest event
More informationMISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE PROVIDED THROUGH HORIZON RISK INSURANCE, LLC. IT IS IMPORTANT
More informationIf you will be submitting claims through a Billing Service/Clearinghouse, please indicate their name below.
Insurance Corporation 1717 W. Broadway P.O. Box 8128 Madison, WI 53708-8190 Phone: (608) 221-4711 Reminders: Please be sure to sign Item 16, Exhibit A! Complete and return all 5 pages Dear EPIC Provider:
More informationBusiness Visa Application
3181 Larchmont Avenue NE, Warren, OH 44483-2498 330.372.8100 * 330.726.0344 * 330.539.6627 * 800.775.7741 www.sscu.net : Business Visa Application App ID: Account Number: Section 1. Business Information
More informationFacade Grant Program APPLICATION
C I T Y O F E A S T C H I C A G O North Harbor Facade Grant Program APPLICATION The City of East Chicago will fund up to 80% of the cost for facade improvements for properties in designated areas within
More informationABM INDUSTRIES INC /DE/
ABM INDUSTRIES INC /DE/ FORM 8-K (Current report filing) Filed 10/14/11 for the Period Ending 10/11/11 Address 551 FIFTH AVENUE SUITE 300 NEW YORK, NY 10176 Telephone 212 297-0200 CIK 0000771497 Symbol
More informationVORNADO REALTY LP FORM 8-K. (Current report filing) Filed 01/16/02 for the Period Ending 01/01/02
VORNADO REALTY LP FORM 8-K (Current report filing) Filed 01/16/02 for the Period Ending 01/01/02 Address 210 ROUTE 4 EAST PARAMUS, NJ 07652 Telephone 212-894-7000 CIK 0001040765 SIC Code 6798 - Real Estate
More informationPayment Bond. as Principal, (Legal title of the Contractor) (Street, City, State, Zip Code) and as Surety, (Legal title of the Surety)
Payment Bond KNOW ALL PERSONS BY THESE PRESENTS, that we: as Principal, (Legal title of the Contractor) (Street, City, State, Zip Code) and as Surety, (Legal title of the Surety) (Street, City, State,
More informationPROGRAM OVERVIEW. Participating Partners:
PROGRAM OVERVIEW In celebration of its 80th Anniversary, Industrial Bank has announced a Small Business Grant Initiative to provide the capital necessary to expand several existing, for profit, entrepreneurial
More informationUS short form 263 Old Country Road Melville, NY 11747 800.545.6776 OPT #2 FAX 631.367.0513
US short form ADI New Account Required Documentation Required Documentation for a New Business Account with ADI and Credit Agreement Thank you for your interest in establishing a business credit account
More informationLIMITED LIABILITY COMPANY INTEREST SALE AND ASSIGNMENT AGREEMENT
LIMITED LIABILITY COMPANY INTEREST SALE AND ASSIGNMENT AGREEMENT THIS LIMITED LIABILITY COMPANY SALE AND ASSIGNMENT AGREEMENT (this Agreement ) is made as of February 5, 2009, by Stearns SPV I, LLC, a
More informationGSV CAPITAL CORP. FORM 8-K. (Current report filing) Filed 04/28/15 for the Period Ending 04/28/15
GSV CAPITAL CORP. FORM 8-K (Current report filing) Filed 04/28/15 for the Period Ending 04/28/15 Address 2925 WOODSIDE ROAD WOODSIDE, CA 94062 Telephone (650) 235-4777 CIK 0001509470 Symbol GSVC Industry
More informationPACIFIC ETHANOL, INC. (Exact name of registrant as specified in its charter)
SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 Date of Report (Date of earliest event reported)
More informationERRORS & OMISSIONS INSURANCE APPLICATION
ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: Indian Harbor Insurance Company 505 Eagleview Blvd. Suite 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 THIS IS AN APPLICATION
More informationKeep these instructions for reference as you complete the registration process.
MARYLAND MEDICAID EDI CONTRACT INSTRUCTIONS (SKMD0) Please MAIL all pages of your completed and signed forms to: MD On-Line ATTN: Enrollment 6 CENTURY DR 2 ND FL PARSIPPANY, NJ 07054 Do not submit your
More informationNATIONAL CONTRACTORS INSURANCE COMPANY, INC., A RISK RETENTION GROUP SUBSCRIPTION AND SHAREHOLDERS AGREEMENT
1 NATIONAL CONTRACTORS INSURANCE COMPANY, INC., A RISK RETENTION GROUP NOTICE SUBSCRIPTION AND SHAREHOLDERS AGREEMENT This policy is issued by your risk retention group. Your risk retention group may not
More informationREGISTERED TRANSFER AGENTS FORM TA-1. Form for Registrations and Updating Amendments
REGISTERED TRANSFER AGENTS FORM TA-1 Form for Registrations and Updating Amendments Revised 2007 Part I - GENERAL INSTRUCTIONS Terms and Abbreviations... 2 Who Must File... 2 Where to File... 3 When to
More informationThank you for your business and choosing Bank of Akron.
Welcome to Bank of Akron, your hometown bank. At Bank of Akron, we appreciate that your time is valuable. That is why we have created a convenient way for you to switch your banking relationship to Bank
More informationALL PETITIONERS MOTION TO CONSOLIDATE THIS CASE WITH CASE No. 04-1247, MAPS, et al. v. US/THOMPSON, et al.
UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT MULTIDISCIPLINARY ASSOCIATION FOR PSYCHEDELIC STUDIES; LYLE CRAKER and VALERIE CORRAL, Petitioners, vs. No. 04-1246 THE UNITED STATES
More informationSasol Supplier Application Form: International All sections to be completed in this document are compulsory
Sasol Supplier Application Form - International Entity Return for completed applications: Contact Centre Tel: +27 17 610 4777 E-mail: supplieradministrator@sasol.com Sasol Supplier Application Form: International
More informationSOUTH CAROLINA MEDICAID EDI CONTRACT INSTRUCTIONS (SKSC0)
SOUTH CAROLINA MEDICAID EDI CONTRACT INSTRUCTIONS (SKSC0) Please carefully read all instructions before beginning. The documents in this top section must be completed and sent to MD On-Line with your contract.
More informationERRORS & OMISSIONS RENEWAL APPLICATION
ERRORS & OMISSIONS RENEWAL APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE
More informationMake the Switch to American Momentum Bank.
Make the Switch to American Momentum Bank. If you are thinking about choosing a new bank, consider American Momentum Bank. It s easy to make the switch to American Momentum Bank. All the forms you ll need
More informationERRORS & OMISSIONS INSURANCE APPLICATION
ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE
More informationSmall Business and Local Preference Program. Most Frequently Asked Questions
Small Business and Local Preference Program Most Frequently Asked Questions What is the Small Business and Local Preference Program? o It is the Washington Metropolitan Area Transit Authority s (WMATA)
More informationBEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION
BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION NOTICE: INSURING AGREEMENTS I.A., I.C., I.D. AND I.F. OF THIS POLICY PROVIDE COVERAGE
More informationACE American Insurance Company
Named Applicant: Date: ACE American Insurance Company ACE Advantage ACE American Insurance Company National Association of REALTORS Professional Liability Name of insurance company to which Application
More informationSTATE OF NEVADA OFFICE OF THE SECRETARY OF STATE
STATE OF NEVADA ROSS MILLER SCOTT W. ANDERSON Deputy Secretary for Commercial Recordings Commercial Recordings Division 202 N. Carson Street Carson City, NV 89701-4069 Telephone (775) 684-5708 Fax (775)
More informationWELCOME. Thank you for your interest in representing A-One Commercial Insurance Risk Retention Group, Inc. (A-One).
WELCOME Thank you for your interest in representing A-One Commercial Insurance Risk Retention Group, Inc. (A-One). Attached you will find the necessary paperwork needed for your appointment. A brief checklist
More informationUNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND ATTORNEY ADMISSION INFORMATION A. FEES Application for Admission.................................. $ 200.00 Application for Renewal....................................
More informationMEDICAID MARYLAND MHA (PMHS) PRE ENROLLMENT INSTRUCTIONS 77062
MEDICAID MARYLAND MHA (PMHS) PRE ENROLLMENT INSTRUCTIONS 77062 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 week. Medicaid Maryland PMHS is administered by Value Options. WHAT FORMS
More informationFLORIDA DEPARTMENT OF STATE DIVISION OF CORPORATIONS
FLORIDA DEPARTMENT OF STATE DIVISION OF CORPORATIONS Attached is a form to convert an Other Business Entity into a Florida Limited Liability Company pursuant to section 608.439, Florida Statutes. These
More informationFLORIDA DEPARTMENT OF STATE DIVISION OF CORPORATIONS
FLORIDA DEPARTMENT OF STATE DIVISION OF CORPORATIONS Attached are the forms and instructions to form a Florida Limited Liability Company pursuant to Chapter 608, Florida Statutes. All information included
More informationNarcotic Treatment Programs
This is a copy of two small segments of the DEA Pharmacist Manual, April 2004. This material is absent from the DEA Practitioner s Manual. Narcotic Treatment Programs The Narcotic Addict Treatment Act
More informationBrokerage and Non-Brokerage Accounts Asset & Financial Planning Account Application
Brokerage and Non-Brokerage Accounts Asset & Financial Planning Account Application Account Number Social Security Number (required) Account Type (please check all that apply) Individual Pension Keogh
More information2014 Educated Eats Future of the Industry Scholarship Application
The Restaurant Association Metropolitan Washington Education Foundation (RAMW-EF), known as Educated Eats, is a non-profit organization dedicated to promoting the restaurant industry as a career of unlimited
More informationBUSINESS ACCOUNT APPLICATION
BUSINESS ACCOUNT APPLICATION Thank you for applying for NASA Federal Credit Union s business account services. To expedite the processing of your application, please note the following requirements: Businesses,
More informationNational Processing Company - Merchant Services Agreement
National Processing Company - Merchant Services Agreement 1. Application Type Merchant #: 496 Store #: New Merchant Additional Location 2. Merchant Business Information Business / DBA Name Corporate/Legal
More informationNON-RESIDENT PHARMACY PERMIT APPLICATION INSTRUCTIONS
NON-RESIDENT PHARMACY PERMIT APPLICATION INSTRUCTIONS Complete the attached Maryland Board of Pharmacy's Application for Non-Resident Pharmacy Permit. The box for the relevant application type (New, New
More informationINFORMATION SHEET MARYLAND CERTIFICATION TO PRACTICE AS A NURSE ANESTHETIST CRITERIA FOR MARYLAND NURSE ANESTHETIST CERTIFICATION
INFORMATION SHEET MARYLAND CERTIFICATION TO PRACTICE AS A NURSE ANESTHETIST CRITERIA FOR MARYLAND NURSE ANESTHETIST CERTIFICATION 1 THE $50.00 APPLICATION-PROCESSING FEE. (CHECK OR MONEY ORDER PAYABLE
More informationPROOF OF CLAIM IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MINNESOTA
PROOF OF CLAIM IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MINNESOTA WILLIAM DEAN, individually, on behalf of himself and all others similarly situated, Plaintiff, Civ. No. 14-cv-00376 DFW/JSM
More information