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rf ntbr nt f f System fitted 128 to hear the recorded. No code aidedunaided minority status Faculty Name of Principal Name of College Address Address Taluka City Pin Year of Establishment STD Code Telephone Telephone Fax Principal Telephone email email 2 Website mobil No code aidedunaided minority status Faculty Name of Principal Name of College Address Address Taluka City Pin Year of Establishment STD Code Telephone Telephone Fax Principal Telephone email email 2 Website mobil ASSUMPTION OF RISK RELEASE OF LIABILITY WAIVER OF CLAIMS ARBITRATION AGREEMENT In consideration of being allowed to use the facilities and SDUWLFLSDWH57347LQ57347SURJUDPV57347DQG57347HYHQWV5734757355575233URJUDPV operated by BROWNSTONE EXPLORATION Further by signing below I certify that I am not indebted to the Federal Government nor do I appear on a Government debarred listing Please indicate below how you learned of this sale GSA Webpage Newspaper Ad FriendRelative SignPoster Radio Ad Other Name: Address: Telephone number: Email address: BLACK LONG SLEEVE T-SHIRT: Sizes /$ L/$23.99 XL/$23.99 XXL/$27.99 XXXL/$29.99 GREY LONG SLEEVE T-SHIRT: Sizes /$ L/$23.99 XL/$23.99 XXL/$27.99 XXX REMIX AGREEMENT Name/Firm: .................................... Address: .................................... Telephone number: .................................... Email address: ................... Position:Organisation:Email address:Telephone number:Workplace address:EligibilityEligibility is at the discretion of the National Scholarship Program Committee and is assessed on the basis of informa Name Business Address:Telephone Residence Address:Telephone for (check one): active membership honorary membership If a former Rotarian, list club(s) and date(s): Proposed classification (if active) HEALTH COVERAGE ENROLLMENT FORM EMPLOYEE/PARTICIPANT INFORMATION SOCIAL SECURITY NUMBER CITY MALE FEMALE HOME PHONE SPOUSE INFORMATION !I More Paqes ollPlospeqtusPlease reter to the inside front cover page and the succeeding pages of the prospectusItem 3. RisLlaqtorlald OtIel hlolrnetrenPlease refer to the section "Risk Factors' on p HEALTH COVERAGE ENROLLMENT FORM EMPLOYEE/PARTICIPANT INFORMATION SOCIAL SECURITY NUMBER CITY MALE FEMALE HOME PHONE SPOUSE INFORMATION IF N ALL BEST HOMECAREPERSONAL DATANAME LAST FIRST MDATEHOME PHONEPRESENT ADDRESS STREET CITY STATE ZIPCELL PHONEEMAILMALE / FEMALEWANT LIVE-IN CARE -YES New Office Location Hospital Based Location Other Independent Diagnostic Center Supplier Etc Street Address Street Address City State Zip City State Zip Description and Volume of Rejected WastePMAMWaste Generation Site/Location Time of Waste RejectionSignatureZIP CodeFacility NameStateCityAddressWHERE THE WASTE WAS FINALLY DISPOSEDE-mail AddressZIP Co