APPLICATION FOR REGULAR MEMBERS

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "APPLICATION FOR REGULAR MEMBERS"

Transcription

1 2013 APPLICATION FOR REGULAR MEMBERS The undersigned hereby makes application for membership in Toy Industry Association, Inc., with the understanding that this membership will remain in force until formally terminated by the Association, pursuant to its by-laws, or by a written request from our company prior to the end of the period for which dues have been paid. COMPANY NAME YEAR BUSINESS WAS ESTABLISHED STREET CITY STATE ZIP/POSTAL CODE COUNTRY PHONE (INCLUDE COUNTRY CODE IF NON-U.S.) FAX (INCLUDE COUNTRY CODE IF NON-U.S.) WEBSITE THE OFFICERS OF THIS COMPANY ARE (if the company is a partnership, give names of the partners): To list additional officers and s, please use a separate sheet and attach to application. CEO NAME & TITLE COO NAME & TITLE CFO NAME & TITLE OUR FIRM IS A (check one): o Corporation under the laws of [State or Province and Country] o Partnership o Sole Proprietorship NUMBER OF EMPLOYEES (company-wide): GENERAL DESCRIPTION OF YOUR PRODUCT LINE(S): DOES YOUR FIRM HAVE SUBSIDIARIES? IF SO, PLEASE NAME: DOES YOUR FIRM OR ANY OF ITS PARENTS, SUBSIDIARIES OR AFFILIATES OWN AND/OR OPERATE ANY RETAIL ENTITIES INCLUDING ONLINE SUBSIDIARIES? IF SO, PLEASE NAME*. IS YOUR FIRM A SUBSIDIARY OR A DIVISION OF A PARENT COMPANY? IF SO, PLEASE NAME: *If during your membership your firm or any of its parents, subsidiaries or affiliates become proprietors of any retail entities and/or online retail subsidiaries you must promptly advise TIA in writing. Regular members shall pay dues in the amount determined by their annual domestic and FOB sales by the company and all affiliated companies of toys and consumer products intended for the youth market in the United States, Mexico and Canada, or by annual net income, in accordance with a schedule developed and approved by the Board of Directors annually. Where separate firms or corporations have merged or consolidated into one firm or association or where one firm or corporation becomes a part of or a subsidiary of the other, then their combined or consolidated sales of toys, games, decorations and allied products shall be considered for the purpose of determining their dues under the schedule. Our dues category as checked below has been computed in accordance with the provisions of Article 13.1 of TIA By-Laws and this schedule. We certify that the sales volume/ income checked below is a true and accurate figure, based upon the information currently available to us, and understand and agree that if TIA should later determine that the figure is incorrect, TIA shall be able to collect any additional dues that may be owed based on a higher sales volume/income than that checked below. MANUFACTURERS ANNUAL NET SALES FOR OUR MOST RECENT FULL FISCAL YEAR ANNUAL NET SALES DUES ANNUAL NET SALES DUES ANNUAL NET SALES DUES ANNUAL NET SALES DUES o Under $1 million $1,725 o 1 to 3 million $3,000 o 3 to 5 million $3,750 o 5 to 8 million $5,000 o 8 to 10 million $7,000 o 10 to 15 million $9,100 o 15 to 20 million $12,500 o 20 to 30 million $16,000 o 30 to 40 million $20,000 o 40 to 50 million $25,000 o 50 to 75 million $32,000 o 75 to 100 million $39,000 o 100 to 150 million $47,000 o 150 to 200 million $56,050 o 200 to 300 million $70,000 o 300 to 400 million $85,000 o 400 to 500 million $100,000 o 500 million to 1B $120,000 o Over 1 billion $250,000

2 RETAILERS ANNUAL GROSS SALES OF TOY PRODUCTS ANNUAL GROSS SALES DUES ANNUAL GROSS SALES DUES ANNUAL GROSS SALES DUES ANNUAL GROSS SALES DUES o Under $1 million $1,725 o 1 to 3 million $3,000 o 3 to 5 million $3,750 o 5 to 25 million $5,000 o 25 to 100 million $10,000 o 100 to 250 million $25,000 o Over 250 million $50,000 LICENSORS ANNUAL WHOLESALE TOY SALES WHOLESALE SALES DUES WHOLESALE SALES DUES WHOLESALE SALES DUES o 0 to 10 million $1,725 o 10 to 25 million $3,000 o 25 to 50 million $3,750 o 50 to 100 million $5,000 o 100 to 250 million $10,000 o Over 250 million $25,000 INVENTOR/DESIGNER ANNUAL NET INCOME ANNUAL INCOME DUES ANNUAL INCOME DUES ANNUAL INCOME DUES ANNUAL INCOME DUES o Under $1 million $1,000 o 1 to 3 million $2,000 o 3 to 5 million $3,000 o Over 5 million $5,000 MANUFACTURERS/SALES REPS ANNUAL NET INCOME ANNUAL INCOME DUES ANNUAL INCOME DUES ANNUAL INCOME DUES ANNUAL INCOME DUES o Under $1 million $2,000 o 1 to 3 million $3,000 o 3 to 5 million $3,750 o Over 5 million $5,500 METHOD OF PAYMENT (Please select one) o By check Check or money order enclosed in the amount of $. Must be US funds and drawn on a US bank. Make checks payable to Toy Industry Association, Inc. o Electronic Funds Transfer Please fill out the enclosed form. o By credit card Please fill out the enclosed form. Add our tax deductible donation to the Toy Industry Foundation in the amount of: o $500 o $1,000 o Other $ Dues information will be regarded as strictly confidential by the Toy Industry Association staff and is not shared with the TIA Board. Similar information is filed by all applicants. A partnership may be represented at meetings of the Association by a partner. A corporation may be represented at meetings of the Association by an officer. Applications for membership and first year s dues shall be submitted to the Member Services Department. A majority vote of the members of the Board of Directors shall be necessary to elect an applicant to membership. MEMBERSHIP DUES ARE NON-REFUNDABLE. ICTI CARE PROCESS Support o YES, our company supports the ICTI Care Process and confirms that within 12 months of joining TIA we will source substantially all of our manufactured/private label toy products from factories in the ICTI CARE Process where it is operational. COMPLETED BY SIGNATURE OF INDIVIDUAL PREPARING FORM NAME OF CEO/CFO TITLE SIGNATURE OF CEO/CFO PHONE FAX Dues, registration fees, advertising, purchase of exhibit space, etc. are not deductible as charitable contributions for federal income tax purposes. Note: this section deals with charitable deductions only, not business or other deductions. To the extent that TIA engages in lobbying activities as defined by Section 162 (e) of the Internal Revenue Code, a portion of your dues would be non-refundable for Federal income taxes. In accordance with the provisions of the Internal Revenue Code Section 6033(e), 50% of the 2013 dues are non-deductible. SEND COMPLETED FORMS WITH PAYMENT TO (INCLUDE COUNTRY CODE IF NON-U.S.) (INCLUDE COUNTRY CODE IF NON-U.S.) TOY INDUSTRY ASSOCIATION, INC. PO Box , Atlanta, GA or fax to (212) Toy Industry Association, Inc.

3 2013 ACH AUTOMATIC PAYMENT/CREDIT CARD NEW MEMBER AUTHORIZATION MEMBER INFORMATION COMPANY NAME COMPANY STREET ADDRESS COMPANY STREET ADDRESS (2 ND LINE) COMPANY CITY STATE / PROVINCE POSTAL CODE COUNTRY In part because of new U.S. banking rules regarding International ACH Transactions (IAT), TIA can only accept domestic ACH transfers. Therefore, only ACH transactions that do not involve a foreign bank can be processed. We apologize for any inconvenience this may cause. On behalf of the above named company, I hereby authorize Toy Industry Association, Inc. to initiate debit entries and adjustments to debit entries (credits) to the commercial checking account or credit card account named below. I hereby authorize Toy Industry Association, Inc. to make these entries based on transactions initiated by the above named company for purchases of goods and services. This authority is to remain in full force and effect until Toy Industry Association, Inc. has received written notification from me or other authorized agent of my company of its termination in such a time and manner as to afford Toy Industry Association, Inc. reasonable opportunity to act on it. TOTAL DUES PAYMENT $ COMMERCIAL CHECKING ACCOUNT INFORMATION PLEASE ATTACH A VOIDED CHECK TO THIS FORM ACCOUNT DEPOSITORY NAME BANK NAME BANK BRANCH BANK CITY STATE / PROVINCE POSTAL CODE ABA TRANSIT NUMBER ACCOUNT NUMBER OFFICIAL SIGNATORY FULL NAME (CLEARLY PRINTED) OFFICIAL SIGNATURE CREDIT CARD ACCOUNT INFORMATION CHARGE $ TO MY CREDIT CARD: o AMERICAN EXPRESS (Only acceptable for dues payments of $70,000 or less) o DISCOVER o MASTERCARD o VISA CARD NUMBER EXPIRATION 3 OR 4 DIGIT SECURITY CODE* CARDHOLDER NAME SIGNATURE * Visa, Mastercard and Discover users The Card ID Number is the 3-digit number located on the back of your card, usually at the top of the signature strip. American Express users Look for the 4-digit number printed on the front of your card. Depending on which card you have, you ll find this number in small type above your credit card s main number on either the left or right side. PROCESSED BY 2012 Toy Industry Association, Inc.

4 TIA MEMBER COMMITMENT TO THE ICTI CARE PROCESS Applicable to manufacturing member companies and/or member companies manufacturing their own private label toys Ethical manufacturing is a responsibility of all companies in the toy industry. The U.S. toy industry can be proud of the measures it has taken to assure that toys sourced in China for the U.S. market are produced in factories that treat their employees fairly and with dignity. The TIA Board of Directors has affirmed the importance of ethical toy manufacturing by unanimously voting to make commitment to the ICTI CARE Process a requirement for membership in the Association. This is a bold policy, and demonstrates that TIA is genuinely dedicated to ethical treatment of toy factory workers. It is also an important response to accusations from critics who claim that our industry exploits children and laborers to produce its toys. Accordingly, companies joining or renewing their membership in the TIA must confirm their commitment to the ICTI CARE Process as follows: Our company supports the ICTI CARE Process for ethical treatment of workers and affirms that wherever that Process is operational we source substantially all of our product (95% or more) from factories that either: have an ICTI CARE Seal (Level A, B or Conditional) are on probation are registered and awaiting audit New members in TIA must confirm that within 12 months of joining the association they will source substantially all of their products from factories in the ICTI CARE Process where it is operational. WHAT IS THE ICTI CARE PROCESS (ICP)? The ICTI CARE Process is the International Council of Toy Industries (ICTI) program to promote ethical manufacturing, in the form of fair labor treatment, as well as employee health and safety, in the toy industry supply chain worldwide. Its initial focus is in China, where 80 percent of the world s toy volume is manufactured. Its intent is to provide a single, fair, thorough and consistent program to monitor toy factories compliance with ICTI s Code of Business Practices (the Code ). CARE stands for: Caring, Awareness, Responsible, Ethical. Additional detailed information about the ICTI CARE Process is available at: Broadway Suite 400 New York NY Tel Fax

5 WHAT IS ICTI? The International Council of Toy Industries (ICTI) was formed in 1974 as an association of toy trade associations from around the world. The products of its 20 member countries encompass the full range of toys, playthings and related merchandise. In 1995, ICTI adopted a Code of Business Practices and, in 1996, it expanded this Code and also adopted a Fire Prevention and Emergency Preparedness Guide to encourage safe conditions in toy factories around the world. Since then, ICTI members have twice revised the code and will continue to do so in future as needed. ICP CONTINUOUS IMPROVEMENT PROCESS. The ICP has begun implementation of its new policy on Wages and Working Hours via a Continuous Improvement Process. This new process, which has been phased in since September 2009, is now in full effect. The goal of this new effort is to improve factory compliance with wages and working hours requirements and to foster improved transparency in this critical area. Instead of the earlier pass-fail system for compliance with wages and working hours requirements, the new Continuous Improvement Process offers toy factories the opportunity to qualify for ICP compliance certification more quickly. This is accomplished by working progressively toward full compliance on wages and working hours over time. WHY SHOULD CONSUMERS FEEL CONFIDENT IN CARE CERTIFICATION? A factory will receive an ICTI CARE Seal of Compliance only if it can demonstrate that it is committed to compliance with the ICTI Code of Business Practices by establishing effective, verifiable, systems to satisfy the Code s provisions. This evaluation will be performed after a rigorous review by an independent third party monitor that has itself been accredited by the ICTI CARE Technical Advisory Council (TAC) Broadway Suite 400 New York NY Tel Fax

RESELLER APPLICATION IMPORTANT NEW ACCOUNT INFORMATION

RESELLER APPLICATION IMPORTANT NEW ACCOUNT INFORMATION Tel : 1 (909) 468-3688 : 1 (909) 628-1755 RESELLER APPLICATION IMPORTANT NEW ACCOUNT INFORMATION Thank you for choosing CG distribution as your premier source of automotive after market lighting and accessories

More information

Business Deposit Account Application - Partnership

Business Deposit Account Application - Partnership - Partnership A partnership is a business in which two or more owners agree on how to share profits and liability. While not required by law, all partnerships should create a written partnership agreement.

More information

NEW CUSTOMER SETUP All fields must be filled out, any supporting documents must be forwarded with request form. City: State: Zip:

NEW CUSTOMER SETUP All fields must be filled out, any supporting documents must be forwarded with request form. City: State: Zip: Palletized Trucking Inc. Accounting PO Box 8744 Houston, TX 77249 8744 713 225 3303 NEW CUSTOMER SETUP All fields must be filled out, any supporting documents must be forwarded with request form CUSTOMER

More information

Quality Linens That Cost Less!

Quality Linens That Cost Less! Quality Linens That Cost Less! Thank you for your interest in A-1 Tablecloth Company Enclosed are the forms to setup your account. Please take a moment to review. Page 2, Credit card form Must be filled

More information

Avella Wholesale, Inc.

Avella Wholesale, Inc. Credit Application Form Applicant Information Applicant Name: Address: Company Information Company Name: DBA Name (If Applicable): Company Address: Tax ID (FEINISSN): Billing Contact: Banking Information

More information

Attestation of Eligibility for an Enrollment Period

Attestation of Eligibility for an Enrollment Period 301 S. Vine St., Urbana, IL 61801 Attestation of Eligibility for an Enrollment Period Typically, you may enroll in a health plan only during the Open Enrollment Period. There are exceptions that may allow

More information

1804 NW Martin Road ~ Forest Grove, OR ~ Phone: (503) ~~ Fax: (503) or

1804 NW Martin Road ~ Forest Grove, OR ~ Phone: (503) ~~ Fax: (503) or 1804 NW Martin Road ~ Forest Grove, OR ~ 97116 Phone: (503) 648-8551 ~~ Fax: (503) 601-3111 or 503 747-5487 www.oregonroses.com! NET 30 NEW ACCOUNT APPLICATION Please, complete all Forms. Failure to do

More information

APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE * UNITED AMERICAN INSURANCE COMPANY A LEGAL RESERVE STOCK COMPANY

APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE * UNITED AMERICAN INSURANCE COMPANY A LEGAL RESERVE STOCK COMPANY UAI2329 1214 0612 - ,. $,. Agent mails completed application and required forms to the home office: United American Insurance CompanyAUTOMATIC PAYMENT PLAN AUTHORIZATION P.O. Box 8080 All premiums may

More information

Payrolls Unlimited, Inc.

Payrolls Unlimited, Inc. Payrolls Unlimited, Inc. www.payrollsunlimited.com Enclosed you will find all the necessary paperwork that needs to be completed in order for us to begin your payroll services. If you have any questions,

More information

The Peoples Bank Business Switch Kit

The Peoples Bank Business Switch Kit Member FDIC The Peoples Bank Business Switch Kit The Peoples Bank is a locally owned community bank. Our focus is on you and the Peoples Bank community in which you live and do business. Seasoned banking

More information

HELPING TEENS THRIVE. Youth & Government CENTRAL YMCA

HELPING TEENS THRIVE. Youth & Government CENTRAL YMCA HELPING TEENS THRIVE Youth & Government CENTRAL YMCA LEARN MORE WHAT IS YOUTH & GOVERNMENT? Learn first-hand how our state government works not by watching, but by doing! Each September for six months,

More information

BUSINESSMAX MEMBERSHIP APPLICATION

BUSINESSMAX MEMBERSHIP APPLICATION One Leo Fraser Dr., Northfield, NJ 08225 ottingergolf.com Atlantic City CC: 609-236-4400 Ballamor GC: 609-601-6220 Scotland Run GC: 856-863-3737 BUSINESSMAX MEMBERSHIP APPLICATION Company Name: Business

More information

DirectCash Bank ("DCBank") Toll Free Fax: and the "Customer" noted below Web Site:

DirectCash Bank (DCBank) Toll Free Fax: and the Customer noted below Web Site: AGREEMENT between Toll Phone: 1-866-231-0373 DirectCash Bank ("DCBank") Toll Fax: 1-866-777-5519 and the "Customer" noted below Web Site: www.dcbank.ca Card balances can be checked 24/7 at the numbers/websites

More information

PREPAID CARDHOLDER AGREEMENT

PREPAID CARDHOLDER AGREEMENT Toll Free Phone: 1-866-231-0373 Toll Free Fax: 1-403-451-3069 Web Site: www.dcbank.ca PREPAID CARDHOLDER AGREEMENT between DirectCash Bank ("DCBank"), and the "Cardholder" PREPAID CARDHOLDER AGREEMENT

More information

Attached is our ACH application. Please take a moment to review the following instructions.

Attached is our ACH application. Please take a moment to review the following instructions. Dear Valued Supplier: Attached is our ACH application. Please take a moment to review the following instructions. 1) Complete attached forms 2) In order to go on ACH payments, CVS Health requires additional

More information

BE A PART OF SOMETHING GREATER Membership Application BRAD AKINS BRANCH

BE A PART OF SOMETHING GREATER Membership Application BRAD AKINS BRANCH BE A PART OF SOMETHING GREATER Membership Application BRAD AKINS BRANCH YMCA Mission: To put Christian principles into practice through programs that build healthy spirit, mind, and body for all. Because

More information

Application to be registered in the University of Venda Supplier Database

Application to be registered in the University of Venda Supplier Database Application to be registered in the University of Venda Supplier Database NB: Forms must be returned by post or hand to the under mentioned address not by faxes or email. TO: Supply Chain Management Section

More information

Business Member Application Sole Proprietorship, Partnership, or Corporation Resolution Directing Account Operations

Business Member Application Sole Proprietorship, Partnership, or Corporation Resolution Directing Account Operations Business Member Application Sole Proprietorship, Partnership, or Corporation Resolution Directing Account Operations REQUIRED DOCUMENTS The Financial Institution will require the following documents, as

More information

Sole Proprietor Membership

Sole Proprietor Membership What is AWO? The American Waterways Operators (AWO) is the national trade association for the domestic waterborne transportation industry, representing the interests of member companies operating on the

More information

ABOUT TOURISM WHISTLER

ABOUT TOURISM WHISTLER ABOUT TOURISM WHISTLER TOURISM WHISTLER S PURPOSE Tourism Whistler is a not-for-profit, Member-based marketing and sales organization, representing more than 7,000 Members who own, manage, and operate

More information

2015 IBWA Bottler Membership Dues Form

2015 IBWA Bottler Membership Dues Form BOTTLER MEMBERSHIP IBWA Bottler members are companies that bottle or package water for sale within the United States (whether or not the plant is located in the United States) and that meet IBWA Bottled

More information

STUDENT REGISTRATON. Emergency Contact: Medical conditions / allergies: Yes No If yes, please explain: Parent/Guardian's Signature:

STUDENT REGISTRATON. Emergency Contact: Medical conditions / allergies: Yes No If yes, please explain: Parent/Guardian's Signature: STUDENT REGISTRATON Student's Name: Age: Male/Female: of Birth: / / Are you a returning Footworks student (Y/N)? Years dance experience: E-mail address: How did you hear about us? (circle) WO TIMES-SW

More information

In addition to the attached application, please submit the following items: Signed current aging of accounts receivable and accounts payable

In addition to the attached application, please submit the following items: Signed current aging of accounts receivable and accounts payable Application Dear Applicant: The following checklist includes additional information First Central Savings Bank requires in order to evaluate your application for a commercial loan. The completion of this

More information

New Membership. MYOB Bookkeeper

New Membership. MYOB Bookkeeper New Membership MYOB Bookkeeper Application Form Thank you for your interest in becoming an MYOB Bookkeeper Partner As a bookkeeper, your clients expect you to have a thorough understanding of Australia

More information

UltraCare plan Individual application form

UltraCare plan Individual application form UltraCare 1 January 2012 UltraCare plan Individual application form If you have any questions or need any help completing this form, please contact your adviser or us. You can find our contact details

More information

CUSTOMS (Import/Export) POWER OF ATTORNEY

CUSTOMS (Import/Export) POWER OF ATTORNEY (1) Check appropriate box: LLC Individual General Partnership Limited Partnership CUSTOMS (Import/Export) POWER OF ATTORNEY Corporation Sole Proprietorship Other (Specify) (2) EIN / SS Number: (3) Importer

More information

CITY OF TORONTO ACT APPLICATION BY TREASURER

CITY OF TORONTO ACT APPLICATION BY TREASURER Assessment Review Board, 655 Bay Street, Suite 1500, Toronto, Ontario M5G 1E5 Phone: (416) 314-6900 or 1-800-263-3237 Fax: (416) 645-1819 or 1-866-297-1822 Website: www.arb.gov.on.ca CITY OF TORONTO ACT

More information

maxima APPLICATION FORM

maxima APPLICATION FORM maxima APPLICATION FORM Broker House: Aon South Africa (Pty) Ltd Tel : 0860 835 2727 Broker Code: AON001M16 SECTION 1 CHOICE OF OPTION Choose ONE product option by placing x in the appropriate box MAXIMA

More information

From: Subject:

From: Subject: IFC! Independent Financial Consultants!! Fax To: Independent Financial Consultants Att: Iracema Fonseca Fax to email: (086) 586-4165 Fax land: (021) 593-3135 : (084) 334-4848 (W) (021) 593-3012 From: Subject:

More information

CERF Savings Plan - 401(a) Plan

CERF Savings Plan - 401(a) Plan Separation from Employment Withdrawal Request 401(a) Plan CERF Savings Plan - 401(a) Plan 98993-02 When would I use this form? When I am requesting a withdrawal and I am no longer employed by the employer/company

More information

Welcome Home! Valid state issued photo identification and a social security card.

Welcome Home! Valid state issued photo identification and a social security card. Welcome Home! In order for us to process your application in the quickest manner possible, we will need the following items when you submit your application. Two most recent pay stubs. Income must be equal

More information

REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT

REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT Pentegra Retirement Services Colorado East Bank & Trust REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT NON- STOCK Balance IMPORTANT NOTICE: Please carefully review the Special Tax Notice Regarding Plan

More information

APPLICATION TO BECOME AN APPROVED SUPPLIER TO COLUMBUS STAINLESS (PTY) LTD (SOUTH AFRICAN ENTITY)

APPLICATION TO BECOME AN APPROVED SUPPLIER TO COLUMBUS STAINLESS (PTY) LTD (SOUTH AFRICAN ENTITY) Purchasing Department P O Box 133 Middelburg 1050 South Africa www.columbusstainless.co.za Tel : +27 13 247 2969 Fax : +27 86 242 6416 E-mail: brand.lynette@columbus.co.za APPLICATION TO BECOME AN APPROVED

More information

INDEPENDENT DEALER GENERAL DISTINGUISHING NUMBER INFORMATION

INDEPENDENT DEALER GENERAL DISTINGUISHING NUMBER INFORMATION Page 1 of 8 INDEPENDENT DEALER GENERAL DISTINGUISHING NUMBER INFORMATION PLEASE READ ALL OF THIS INFORMATION CAREFULLY BEFORE COMPLETING AND MAILING YOUR APPLICATION. INCOMPLETE OR INACCURATE INFORMATION

More information

Membership Application & Indemnity Agreement

Membership Application & Indemnity Agreement Massachusetts Retail Merchants Workers Compensation Group, Inc. Membership Application & Indemnity Agreement organized and sponsored by: P.O. Box 859222-9222 / Braintree, MA 02185 / 781-843-0005 / 800-790-8877

More information

Function and Catering Agreement

Function and Catering Agreement Function and Catering Agreement I have read and accept the conditions stated in this Agreement and that my deposit is refundable based on the minimum bar spend and the safety of the hotel guests: Date

More information

Spectera UHC VISION PLAN* ENROLLMENT INSTRUCTIONS

Spectera UHC VISION PLAN* ENROLLMENT INSTRUCTIONS Spectera UHC VISION PLAN* ENROLLMENT INSTRUCTIONS Please Type or Print Clearly using only Black Ink, DO NOT USE Felt Tip Pens. MEMBER / APPLICANT INFORMATION: Member/Applicant: Local REALTOR Assoc. Name:

More information

Welcome to the DT Global, Inc family. Establishing open terms will allow the most efficient method of product purchase and delivery.

Welcome to the DT Global, Inc family. Establishing open terms will allow the most efficient method of product purchase and delivery. DT Global, lnc NEW ACCOUNT Welcome to the DT Global, Inc family. Establishing open terms will allow the most efficient method of product purchase and delivery. Please read and complete the enclosed forms

More information

PAYROLL DIRECT DEPOSIT FORM

PAYROLL DIRECT DEPOSIT FORM Check one: PAYROLL DIRECT DEPOSIT FORM If you are wanting to deposit to multiple accounts, please complete a separate form for each account. Set up new account Change existing account Store # Add additional

More information

1880 Radcliff Ct. Tracy, CA (877) , FAX (269) GENERAL APPLICATION FOR MEMBERSHIP

1880 Radcliff Ct. Tracy, CA (877) , FAX (269) GENERAL APPLICATION FOR MEMBERSHIP National Association of 1880 Radcliff Ct. Tracy, CA 95376 (877) 344-0624, FAX (269) 978 9078 Email: admin@naiia.com GENERAL APPLICATION FOR MEMBERSHIP (A $200 application fee and proof of current Professional

More information

GoodNeighborInsurance. 690E.WarnerRd.Suite117 Gilbert,AZ85296,USA

GoodNeighborInsurance. 690E.WarnerRd.Suite117 Gilbert,AZ85296,USA GoodNeighborInsurance AFTERFILLING OUTTHISAPPLICATION PLEASEMAIL,FAX,OREMAILSCANTO: GoodNeighborInsurance 690E.WarnerRd.Suite117 Gilbert,AZ85296,USA TolFree:866-636-9100 Phone:480-633-9500 Fax:480-813-9930

More information

TABLE OF CONTENTS. Introduction 3. General Guidelines for Successful Account Management 3. Managing Your Checking Account. 1.

TABLE OF CONTENTS. Introduction 3. General Guidelines for Successful Account Management 3. Managing Your Checking Account. 1. TABLE OF CONTENTS Introduction 3 General Guidelines for Successful Account Management 3 Managing Your Checking Account 1. Check Register 2. Planning 3. Recording Your Transactions 4. Balancing Your Account

More information

LOBBY REGISTRATION FOR 2018 (For use through December 31, 2018)

LOBBY REGISTRATION FOR 2018 (For use through December 31, 2018) LOBBY REGISTRATION FOR 2018 (For use through December 31, 2018) COVER SHEET PG 1 The Form REG Instruction Guide explains how to fill out this form. 1 Number of Schedules filed: A B Filer ID OFFICE USE

More information

LEASE APPLICATION PROCESS

LEASE APPLICATION PROCESS LEASE APPLICATION PROCESS There is a non-refundable fee of $75 per applicant/ guarantor for the credit verification process. ALL documents concerning your application can be faxed to 212.251.9610 or emailed

More information

Application for Utility Account Property Folio #

Application for Utility Account Property Folio # Application for Utility Account Property Folio # (This number can be found on the BCPA.net website Pursuant to Part II, Chapter 70, of the City of North Lauderdale s ( City ) City Code ( Code, ) water,

More information

maxima APPLICATION FORM

maxima APPLICATION FORM maxima APPLICATION FORM SECTION 1 CHOICE OF OPTION Choose ONE product option by placing x in the appropriate box Comprehensive Options Saver Options Hospital Plans MAXIMA PLUS MAXIMA EXEC MAXIMA STANDARD

More information

DANVILLE FAMILY YMCA SCHOLARSHIP APPLICATION

DANVILLE FAMILY YMCA SCHOLARSHIP APPLICATION DANVILLE FAMILY YMCA SCHOLARSHIP APPLICATION 1 This is an application for financial aid toward YMCA membership and program fees. Please note that applying for financial assistance does not mean you will

More information

Louisiana Public Employees Deferred Comp. Plan

Louisiana Public Employees Deferred Comp. Plan Separation from Employment Withdrawal Request Governmental 457(b) Plan Louisiana Public Employees Deferred Comp. Plan 98228-01 When would I use this form? When I am requesting a withdrawal and I am no

More information

Sign-up online at or complete & return

Sign-up online at  or complete & return Print or Type all information Sign-up online at www.bitsworkshop.org/expo or complete & return EXPO Application March 5 8, 2017 Hilton Phoenix/Mesa Mesa, Arizona COMPANY INFO (Company Name, Address & Website

More information

FLYERS AFTER SCHOOL PROGRAM APPLICATION FOR CHILD. Childs Information. Date of Application: Child s Name (first & last name)

FLYERS AFTER SCHOOL PROGRAM APPLICATION FOR CHILD. Childs Information. Date of Application: Child s Name (first & last name) FLYERS AFTER SCHOOL PROGRAM 2014-2015 APPLICATION FOR CHILD *All information must be complete in order to enroll Childs Information Child s Name (first & last name) Name of School and Grade Date of Birth

More information

AFFIDAVIT OF UNAUTHORIZED CHECK / DEBIT WITHDRAWAL(S)

AFFIDAVIT OF UNAUTHORIZED CHECK / DEBIT WITHDRAWAL(S) AFFIDAVIT OF UNAUTHORIZED CHECK / DEBIT WITHDRAWAL(S) IMPORTANT: The person alleging an unauthorized withdrawal must complete this form in longhand, using black ink only. I,, being first duly sworn, hereby

More information

Effective January 1, 2018, our name and logo will officially be:

Effective January 1, 2018, our name and logo will officially be: September 29, 2017 New Name, Same Great Credit Union Your Board of Directors and the employees of Sarasota Municipal Employees Credit Union are pleased to make an important announcement that will help

More information

Quick Reference Guide

Quick Reference Guide Driver s License State Issued Federal Government Driver s License State Issued Federal Government NO YES NO Quick Reference Guide Merchant Services Hotline 800-333-108 Hours: Monday-Saturday 8:00am-10:00pm

More information

Payment Options Forms and Tuition Refund Plan Enrolment Form

Payment Options Forms and Tuition Refund Plan Enrolment Form Payment Options Forms and Tuition Refund Plan Enrolment Form 2018-2019 International Students St. Michaels University School Financial Services Office 3400 Richmond Road, Victoria, British Columbia, Canada

More information

EXHIBIT CONTRACT. Annual Meetings 2017 Boston, MA November Booth Choice (Please enter booth numbers from diagram) 1st 2nd 3rd 4th 5th 6th

EXHIBIT CONTRACT. Annual Meetings 2017 Boston, MA November Booth Choice (Please enter booth numbers from diagram) 1st 2nd 3rd 4th 5th 6th EXHIBIT CONTRACT Company Name (To Be Listed in Program) Contact Person Address City, State/Province, Postal Code, Country Web Address Telephone Fax Email Booth Choice (Please enter booth numbers from diagram)

More information

Direct Debit Authorization Form (Banking)

Direct Debit Authorization Form (Banking) Direct Debit Authorization Form (Banking) Principal Logo Reference ID Principal Name z 1. CUSTOMER INFORMATION * This is a mandatory field. First Name * Last Name * Date of Birth * Address Line 1 * Address

More information

2017 Canadian Tire Jumpstart Application Form

2017 Canadian Tire Jumpstart Application Form 2017 Canadian Tire Jumpstart Application Form The Canadian Tire Jumpstart Program supports getting kids in the game by assisting with the costs associated with registration, equipment and/or transportation

More information

Company Name. Company Rep. Title. Address. City State Zip. Phone # ( ) Fax # ( ) Toll Free Phone # ( ) Website

Company Name. Company Rep. Title. Address. City State Zip. Phone # ( ) Fax # ( ) Toll Free Phone # ( )  Website FPGA/NPGA ACTIVE INTRASTATE DEALER 2017 MEMBERSHIP APPLICATION Please complete and return this form along with your MC, Visa or check made payable to: FLORIDA PROPANE GAS ASSOCIATION, P.O. BOX 11026, TALLAHASSEE,

More information

Application Form 2017 P.O. Box 1101, Florida Glen 1708 Call Fax (011)

Application Form 2017 P.O. Box 1101, Florida Glen 1708 Call Fax (011) Application Form 2017 P.O. Box 1101, Florida Glen 1708 Call 0860 002 108 Instructions This form must be completed after reading through the 2017 Bonitas Product Brochure. Please complete the form in full

More information

Producer Application

Producer Application 5300 Adolfo Road, Suite 200 Camarillo, California 93012 United with you on the road Marketing NAIC Number 10920 866-530-5500 Fax 800-761-8680 www.allianceunited.com Unidos contigo en el camino Producer

More information

Discount Window Lending Agreement Instructions

Discount Window Lending Agreement Instructions Federal Reserve Bank of Atlanta Discount Window Lending Agreement Instructions Operating Circular 10 Federal Reserve Bank of Atlanta Discount Window Lending Agreement Instructions 2 Table of Contents Discount

More information

If you do not wish to renew your licence online, you may complete and return this renewal application form to the Council s office.

If you do not wish to renew your licence online, you may complete and return this renewal application form to the Council s office. LICENCE RENEWAL LICENCE RENEWAL PROCESS Approximately six weeks before your licence expiry date, you will receive an email notifying you that your renewal application is due, with instructions for renewing

More information

IMPORTANT ACCOUNT INFORMATION FOR OUR CUSTOMERS from. Union State Bank 545 Main Street Everest, KS (785)

IMPORTANT ACCOUNT INFORMATION FOR OUR CUSTOMERS from. Union State Bank 545 Main Street Everest, KS (785) IMPORTANT ACCOUNT INFORMATION FOR OUR CUSTOMERS from Union State Bank 545 Main Street Everest, KS 66424 (785)548-7521 ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES Indicated below are types

More information

NATIONAL MINORITY SUPPLIER DEVELOPMENT COUNCIL MINORITY-CONTROLLED CERTIFICATION APPLICATION

NATIONAL MINORITY SUPPLIER DEVELOPMENT COUNCIL MINORITY-CONTROLLED CERTIFICATION APPLICATION NATIONAL MINORITY SUPPLIER DEVELOPMENT COUNCIL MINORITY-CONTROLLED CERTIFICATION APPLICATION GENERAL INFORMATION: When answers require additional space, use plain white paper. Properly identify the item

More information

E-Teller In Branch Paper Statement Statement Visa Fraud Prevention Phone MSR. Other:

E-Teller In Branch Paper Statement  Statement Visa Fraud Prevention Phone MSR. Other: Account Number: Last 4 Digits of Card: Card Fraud Questionnaire How did you discover the fraudulent transactions on your account? (Circle One) E-Teller In Branch Paper Statement Email Statement Visa Fraud

More information

Coverdell Education Savings Account Application

Coverdell Education Savings Account Application >> Mail to: Mairs & Power Funds c/o U.S. Bancorp Fund Services, LLC PO Box 701 Milwaukee, WI 53201-0701 Coverdell Education Savings Account Application In compliance with the USA PATRIOT Act, all mutual

More information

PENSION FUND DEPOSIT ACCOUNT 2

PENSION FUND DEPOSIT ACCOUNT 2 PENSION FUND DEPOSIT ACCOUNT 2 Provided by Scottish Widows Bank SUMMARY BOX PLEASE READ THIS SUMMARY BOX BEFORE YOU COMPLETE THE APPLICATION AND THEN KEEP IT FOR YOUR RECORDS. DON T RETURN IT WITH THE

More information

Personal Accounts Retirement Accounts Trust/Other Accounts Business Accounts. (Go to Section 2) (Go to Section 2) (Go to Section 4) (Go to Section 4)

Personal Accounts Retirement Accounts Trust/Other Accounts Business Accounts. (Go to Section 2) (Go to Section 2) (Go to Section 4) (Go to Section 4) C-Share Standard Asset Allocation Program Application Initial Investment is $5,000 for IRAs and $10,000 for all other accounts Overnight Mail Regular Mail Phone: 800-442-4358 Dunham Trust Company ( DTC

More information

VISA BUSINESS, VISA BUSINESS PERFORMANCE AND LAURENTIAN BANK VISA BUSINESS CREVIER

VISA BUSINESS, VISA BUSINESS PERFORMANCE AND LAURENTIAN BANK VISA BUSINESS CREVIER VISA BUSINESS, VISA BUSINESS PERFORMANCE AND LAURENTIAN BANK VISA BUSINESS CREVIER LIABILITY WAIVER INSURANCE This program is insured by Royal & Sun Alliance Insurance Company of Canada. The policy number:

More information

Application Information

Application Information U.S. Member Agreement & Essential Rewards Enrollment Form Application Information 3125 Executive Parkway Lehi, UT 84043 USA Name (Last, First, Middle) Required Social Security or Federal ID Number (Required,

More information

APPLICATION FOR REPRESENTATIVE, ASSOCIATE OR MANAGING BROKER LICENCE

APPLICATION FOR REPRESENTATIVE, ASSOCIATE OR MANAGING BROKER LICENCE APPLICATION FOR REPRESENTATIVE, ASSOCIATE OR MANAGING BROKER LICENCE PART A NATURE OF APPLICATION Type of applicant (please check) First-time applicant (Submit criminal record check with application. See

More information

Credit Cards Conditions of Use

Credit Cards Conditions of Use Credit Cards Conditions of Use Privacy Statement and Consent to Use Your Information 1 February 2018 About these Conditions of Use Your Card Contract comprises: 1. these Conditions of Use; 2. the Credit

More information

BBVA Compass Commercial Card Agreement

BBVA Compass Commercial Card Agreement BBVA Compass Commercial Card Agreement Company: Date: THIS COMMERCIAL CARD AGREEMENT (the Agreement ) is made and entered into as of the date set forth above by the company whose name is set forth above

More information

3776 S.R. 93 N.E., Crooksville, OH Toll Free (866) * Phone (740) * Fax (740)

3776 S.R. 93 N.E., Crooksville, OH Toll Free (866) * Phone (740) * Fax (740) 3776 S.R. 93 N.E., Crooksville, OH 43731 Toll Free (866) 818-4435 * Phone (740) 982-3030 * Fax (740) 982-3055 www.valueautoauction.com Name of Dealer: Telephone ( ) (Legal Name if Different) Fax# ( ) (Hereinafter

More information

Bank of China Bangkok Branch Great Wall International Credit Card User Guide

Bank of China Bangkok Branch Great Wall International Credit Card User Guide Bank of China Bangkok Branch Great Wall International Credit Card User Guide How to recognize the card p. 2 How to activate the card and set up the passwords p. 2 How to use the card.. p. 3 Account Management...

More information

Please be aware that spaces for the Brooklyn Book Festival sold out by April 15th last year.

Please be aware that spaces for the Brooklyn Book Festival sold out by April 15th last year. Brooklyn Book Festival Exhibitor Registration Information and Agreement for Festival Day (September 16, 2018) and BKBF Children's Day (September 15, 2018) Exhibitor Package Table with Canopy one canopy

More information

THANK YOU FOR YOUR INTEREST IN BILL HICKS & CO., LTD

THANK YOU FOR YOUR INTEREST IN BILL HICKS & CO., LTD BILL HICKS & CO., LTD. Office: (763) 476-6200 15155 23 RD Avenue North Fax: (763) 476-8963 Minneapolis, Minnesota 55447-4740 Toll Free: (800) 223-0702 THANK YOU FOR YOUR INTEREST IN BILL HICKS & CO., LTD

More information

New Client Checklist (2 to 100)

New Client Checklist (2 to 100) New Client Checklist (2 to 100) Welcome to PayFlex. The first step in the set up process is completion of the New Client Checklist Form. We use this form to collect critical information about your plan.

More information

U.S. Banking System Overview

U.S. Banking System Overview Date Here U.S. Banking System Overview Banking is regulated by federal and state governments Privacy Disclosure Fraud protection Protection against dishonest lending Lending to low-income populations U.S.

More information

Business Name. Principal(s) Name(s) Mailing Address. City State Zip. Business Phone. Mobile Phone. Fax # . Web Address

Business Name. Principal(s) Name(s) Mailing Address. City State Zip. Business Phone. Mobile Phone. Fax #  . Web Address COIN DEALER P.O. Box 4389 800-287-7127 Davidson, NC 28036 FAX: 704-895-0230 www.aciginsurance.com Antiques & Collectibles National Association The Antiques and Collectibles National Association (ACNA)

More information

Texas Funeral Service Commission Funeral Establishment Application Guidelines

Texas Funeral Service Commission Funeral Establishment Application Guidelines Texas Funeral Service Commission Funeral Establishment Application Guidelines All applicants when applying for a new establishment license must comply with Texas Occupations Code Section 651.351, Funeral

More information

New York 2017/2018 Business Enrollment Form (Auto-Renewal)

New York 2017/2018 Business Enrollment Form (Auto-Renewal) New York 2017/2018 Business Enrollment Form (Auto-Renewal) Instructions This is the application for a special case enrollment that allows New York small groups to enroll in health coverage for 2017 (starting

More information

New Know Before You Owe disclosures for Reloadable prepaid accounts

New Know Before You Owe disclosures for Reloadable prepaid accounts New Know Before You Owe disclosures for Reloadable prepaid accounts The SHORT FORM DISCLOSURE highlights the most important fees, enabling BluCurrent members to compare reloadable prepaid accounts and

More information

CHECKING ACCOUNT TYPES

CHECKING ACCOUNT TYPES CHECKING ACCOUNT DISCLOSURE This disclosure contains information about terms, fees, and interest rates for some of the accounts we offer. CHECKING ACCOUNT TYPES ValueAccess Checking with BaZing Rate Information:

More information

HSBC Money Market Funds

HSBC Money Market Funds HSBC Money Market Funds Direct Account Application: 1. Complete a new account application. Return completed form to: HSBC Funds PO Box 8106, Boston MA 02266-8106 For assistance, call: 1-877-244-2424 (Institutional)

More information

Princeton Community Hospital Defined Contribution 403(b) Plan

Princeton Community Hospital Defined Contribution 403(b) Plan Separation from Employment Withdrawal Request 403(b) Plan Princeton Community Hospital Defined Contribution 403(b) Plan 95791-01 When would I use this form? When I am requesting a withdrawal and I am no

More information

THE GEORGE WASHINGTON UNIVERSITY STUDENT ACCOUNT EBILL SOLUTION TERMS AND CONDITIONS

THE GEORGE WASHINGTON UNIVERSITY STUDENT ACCOUNT EBILL SOLUTION TERMS AND CONDITIONS THE GEORGE WASHINGTON UNIVERSITY STUDENT ACCOUNT EBILL SOLUTION TERMS AND CONDITIONS These Terms and Conditions are designed to provide you with information related to the George Washington University

More information

CONSUMER ELECTRONIC FUNDS TRANSFER AGREEMENT AND DISCLOSURES

CONSUMER ELECTRONIC FUNDS TRANSFER AGREEMENT AND DISCLOSURES CONSUMER ELECTRONIC FUNDS TRANSFER AGREEMENT AND DISCLOSURES This Agreement and Disclosure is made in compliance with federal law regulating consumer electronic funds transfer (EFT) services. Consumer

More information

Instructions for Retailer Application Packet

Instructions for Retailer Application Packet Instructions for Packet PART 1 Business Information The application to become a Tennessee Education Lottery (TEL) Retailer must be accompanied by a Cashier s Check, Business Check or Money Order for $95

More information

Deja Vu Credit Application August 2015

Deja Vu Credit Application August 2015 Deja Vu Credit Application August 2015 Deja Vu Wine Company Pty Ltd ABN 79127368629 PO Box 387 Abbotsford VIC 3067 Bank Account: HSBC BSB: 343 001 ACC: 328 103 299 Customer Service Email Phone Fax Orders

More information

Switch Kit. See the light and make the switch. Make us your number ONE.

Switch Kit. See the light and make the switch. Make us your number ONE. Switch Kit See the light and make the switch Make us your number ONE. 843 40 th Ave NE Columbia Heights, MN 55421 11465 Robinson Dr. Coon Rapids, MN 55433 10210 Baltimore St NE Blaine, MN 55449 763-404-7600

More information

California State Firefighters Association Volunteer Firefighters Length of Service Award Program

California State Firefighters Association Volunteer Firefighters Length of Service Award Program California State Firefighters Association Volunteer Firefighters Length of Service Award Program Sponsored by: The California State Firefighters Employee Welfare Benefits Corporation (CSFEWBC) Administered

More information

5. Partial trips can be priced on an individual basis. Please contact me by with details and I will be glad to provide you with a quote.

5. Partial trips can be priced on an individual basis. Please contact me by  with details and I will be glad to provide you with a quote. Demonstrating the historical reliability of the Bible through archaeological and Biblical research. Dear Future Digger, Greetings in the name of Jesus Christ, our Lord! Thanks for expressing an interest

More information

ACCOUNT INFORMATION FORM

ACCOUNT INFORMATION FORM ACCOUNT INFORMATION FORM Please read this Agreement in its entirety carefully, as this document will help us understand your needs and expectations with regard to this account, and establish certain provisions

More information

Merchant Application & Agreement (INDIA)

Merchant Application & Agreement (INDIA) Merchant Application & Agreement (INDIA) MERCHANT ID - Business Information Merchant's DBA Name/Outlet Merchant's Legal / Registered Physical Address (No P.O. Box): Legal / Registered Address: Unit Floor

More information

Walter F. Ehrnfelt Recreation Center Royalton Road, Strongsville, Ohio

Walter F. Ehrnfelt Recreation Center Royalton Road, Strongsville, Ohio Annual Membership Packages for the Walter F. Ehrnfelt Recreation Center 18100 Royalton Road, Strongsville, Ohio 44136 440.580.3260 www.strongsville.org Fees effective as of October 1, 2014 You now have

More information

Application to be registered in the University of Venda Supplier Database

Application to be registered in the University of Venda Supplier Database Application to be registered in the University of Venda Supplier Database NB: Forms must be returned either by post or hand to the under mentioned address and not via faxes or e-mail. TO: Head: Supply

More information

Instructions for Fax or Applications for Service

Instructions for Fax or  Applications for Service 845 Galvez Street, Mandeville, LA 70448-4934 985.626.5132 www.h2osystemsinc.com Instructions for Fax or Email Applications for Service To complete your application for water and sewer services via fax

More information

CERF Savings Plan - 401(a) Plan

CERF Savings Plan - 401(a) Plan Death Benefit Claim Request 401(a) Plan CERF Savings Plan - 401(a) Plan 98993-02 When would this form be used? When the Claimant is making a claim on this account due to the death of the Participant (Decedent).

More information

Managed Funds Application Form

Managed Funds Application Form July 2017 Managed Funds Application Form This application form is for investment in the Australian Ethical Managed Funds. Interests in the Australian Ethical Managed Funds are issued by Australian Ethical

More information