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Petition to Reinstate Class Schedule Complete this petition to request a complete reinstatement of all courses dropped for nonpayment Partial schedule reinstatements will not be accepted he schedu. 574005739157393573975739157394573925739357396 Company Website Contact Phone Email Territory Served 574095744457441574535737657428573905737657417 Network ID tudent Loca l Address Street AptBox City State MI End Sponsor will pay for the following check all that apply Full Tuition Health Services Partial Tuition indicate percentage or amount Medical Insurance Mandatory Fees Yes if yes state amo How do you choose the right one for you Compare cell pho ne companies Look at customer satisfaction turnover rate and digital network Can you roam on other networks Make sure the basics of your cell phone service are covered before you start discuss Policy Please List any medications medical problems or disabil ties that pertain to your Child Is your child allergic to anything Past surgery Any d etary restrictions AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT IF MY CHILD SHOULD B O Boxes ll owed Department Street SuiteRoom Number City State AR Zip Phone Service Requested New Service Preferred Service Area Local City Area Code Prefix Little Rock Upgrade phone equipment List Cingular 10 Digit Phone Convert Cingular Service S citizen Yes No If you answered Yes to the question above please respond to the following two questions If your answer was No skip to the following section Are you HispanicLatino Yes No Indicate your race by choosing American Indian or Alaska Native A 6 6 8 6 86 A 6 6886866 6 L8 6 66 6 7 79 6 9 866 6 7 99 7 6 L 6 6 7 9 6 6 7 6 L 6 L 9 6 8 8 9 6 6 9 6 1 ABOUT THE NAKED DSL SERVICE DESCRIPTION Our Customer Relationship Agreement 11 This is the Naked DSL Service Description of ou r CRA under which we supply a Naked DSL Service to you Prior to Cutover to the N aked DSL Service the terms and conditio 1 Contact: [CONTACT NAME, CONTACT ORGANIZATION, PHONE, EMAIL] [INSERT ORGANIZATION NAME] Joins the National #GivingTuesday Movement To Encourage Spending With A Purpose Pledges to [INSERT CAMPAIGN DE ` Name: Address: City: State/Zip: Home Phone: Email: Employer: Cell Phone: Work Phone: Cell Phone #2: Work Phone #2: Emergency Information Name: Phone: Name: Phone: How did you hear about The UltiMu 1800 Customer Service Number is the largest and most trusted customer Service Number directory with contact information over 90% of US & Canada Jason Williams, Corporate Web Manager. Cornwall Council. Where we were. What we have now – Face to Face. 23 One Stop Shops. 36 libraries. What we have now - Phones. 17 Published Numbers. Camborne. General Enquiries. 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Shipping Details:Street AddressCityStateZipAttachments: donations@hevishot.com or fax # 541-367-3552 Please fill out if different from the contact address above. P Defect Y/N Kidney Disease YIN Cancer YIN Learning Disability Y/N COPD Y/N Do you smoke now DYES D NO Packs/day 025 05 -1 -15 -2 3 Years -05 -1 No Do you consume caffeine DYES D Marital Status DSi