Analyzed business checking accounts terms & charges disclosure the following information was correct as of: current rate information may be obtained by contacting your branch at telephone number: product (x) indicates account selected method used...
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Application- liaison traveler official use only: cert#: processed: applicant information mr. mrs. miss ms last name: first name: mi date of birth: / / (month/day/year) passport number: issuing country: what do you consider your home country?...
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Applicant s name: .. form r recommendation form (2013 entry) united world colleges hong kong selection 2013 entry to the applicant: 1. fill in your name on the top of each of the following pages of the recommendation form. 2. you may ask your...
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Outtake form date: your wellbeing is important to us. this outtake form allows us to learn more about our effectiveness and how we can serve you better. if we can assist you in any way in the future, please feel free to contact us again. all...
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Drivetime tobacco use affidavit beginning january 1, 2013, all employees and their spouses/domestic partners are required to complete the tobacco use affidavit to be eligible for participation in our wellness program and our lower wellness...
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K07002307 jun/7/2002 m sca,test visit er0145/12 hcn: 22 van den hof, test / test, maureen early pregnancy complications clinic (epcc) referral form dec/8/2012 6th floor gynecology clinics, 6a women s site, iwk health centre open monday?friday 8:30...
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Return completed form to: (insert name and department) payroll deduction authorization employee name: work number: dept. home address: city state zip i hereby authorize to deduct from my salary, until further notice,$ per pay period to support the...
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Center for health statistics patient id number: / date termination performed: / (month/day/year) (patient id/facility chart/case no.) report of induced termination of pregnancy facility worksheet 1. clinical estimation of gestational age completed...
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Navajo county agenda item request form meeting date: january 13, 2015 requesting department: health time needed: consent presenter(s) name: mary herring, director motion before the board: approve teen pregnancy prevention contract adhs130323...
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A m e r i c a n i n s t i t u t e o f c e rt i f i e d p l a n n e r s the professional institute of the american planning association practicing planner order form rate effective through september 30, 2005 o n e y e a r s u b s c r i p t i o n t...
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Organizational memorandum of understandingand release from liability agreementa. voluntary program participation: i acknowledge that i have voluntarily applied toparticipate in the team happy foundation (thf) internship program or...
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Penguin induced b transition form factor in light cone qcd t. m. aliev , m. savc physics department, middle east technical university, 06531 ankara, turkey abstract we calculate the penguin form factor for the b + decay. this form factor is...
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State of georgia form g-4 (rev. 11/02) employee s withholding allowance certificate 1a. your full name 1b. your social security number 2a. home address (number, street, or rural route) 2b. city, state and zip code please read instructions on...
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Clear form qualified research activities credit name of taxpayer (as shown on return) tax year fein bin method 1 credit based on federal computation (ors 317.152) part i. payments for basic research: (include only amounts paid or incurred in...
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