2-B. Fire Hydrant Testing and Maintenance Required Documents.pdf

RFP P26109, Fire Hydrant Testing and Maintenance Services

COBB COUNTY SCHOOL DISTRICT

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

ACKNOWLEDGEMENT AND AGREEMENT

Request for Proposal P26109, Fire Hydrant Testing and Maintenance Services

This acknowledgement and agreement must be properly signed and submitted with your proposal. The acknowledgement becomes a part of your proposal and without it, your proposal is not complete and will be subject to rejection.

I, the undersigned, have carefully examined and fully understand both the CCSD General Terms and Conditions and this solicitation in their entirety and agree to conform with every requirement. I certify that I am authorized to sign this proposal for the vendor. I further acknowledge that failure to prepare, submit, or execute this proposal in the exact manner requested will be just cause to reject any or all of my proposal submission.

Withdrawals, cancellations, etc., will not be accepted unless authorization is given by the Director of Procurement Services. In the event my company fails to comply, my company may be removed from the vendors’ list.

Failure to respond using the most recent forms/information posted to the CCSD Current Solicitations website may be a cause for rejection. It is my company’s responsibility to check the CCSD Current Solicitations website for any addenda, responses to vendor questions, or other communications, which may be necessary during the solicitation period. I acknowledge and incorporate each applicable Addendum number listed below in my company’s response:

Check all that apply: Addendum No. 1 _____, Addendum No. 2 _____, Addendum No. 3 _____ Addendum No. 4 _____, No Addenda_____

Prices must remain firm as specified on the award notification letter

Company Name Representative’s Name (type or print)

Address Representative’s Signature (must be signed in ink)

City, State, and Zip Code E-Mail Address

Date Telephone Number and Extension

Terms (Net 30 days unless early payment discount Fax Number is submitted and accepted by the CCSD.)

Signing the Acknowledgement and Agreement affirms that the original Request for Proposal document has not been altered in any way.

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

VENDOR QUESTIONNAIRE

Company Name:

1. How many years has your company, or subcontractor, been in the business of providing the goods and services requested?

2. Have you done business with other school systems? Yes ☐ No ☐

If yes, name the system and volume of business

3. Is the vendor willing to extend all pricing, terms and conditions offered to any Metro- Atlanta area and or surrounding counties/cities/K12 School District and/or to any Cobb County government agency? This includes the Cobb County Government, cities within Cobb County, the Devereux Foundation School, and Cobb County Charter Schools. Metro- Atlanta and surrounding areas include, but are not limited to, Fulton, DeKalb, Paulding, Douglas, Bartow, Clayton, Cherokee, Gwinnett, and Forsyth. Yes ☐ or No ☐

4. Are any goods purchased under this solicitation made in the State of Georgia?

Yes ☐ No ☐ NA ☐

If yes, please identify by product name and applicable items

5. Business Type: Check all that apply.

Minority Owned ☐ Disability Owned ☐ Veteran Owned ☐

Small Business ☐ Woman Owned ☐

6. Provide complete contact information for a point of contact DURING EVALUATION period.

This person must be available to answer any questions about your response that may arise before the award. If no information is provided below, the information on the Acknowledgement and Agreement form will be used.

Company Name:

Contact Name:

Phone Number: Fax Number:

Email Address:

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

7. Provide complete contact information for each of the following. If no information is provided below, the information on the Acknowledgement and Agreement Form will be used. NOTE: An IRS W-9 form must be submitted with the response.

Service Representative This person will be responsible for answering CCSD questions related to products, billing issues, etc. during term of contract.

Company Name:

Address:

City: State: Zip:

Contact Name:

Telephone: Fax:

Contact Email:

Purchase Order Address

Address:

City: State: Zip:

Contact Name:

Telephone: Fax:

Contact Email:

Indicate whether purchase orders are to be sent via fax or email. □ Fax or □ Email (preferred)

PO Fax: PO Email Address:

Payment (Remit) Address

Address:

City: State: Zip:

Contact Name:

Telephone: Fax:

Contact Email:

Checks should be made payable to:

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

REFERENCES (Provide your company references):______________________________________ Insert Your Company Name

ALL responding vendors must provide references for your company below. It is the vendor’s responsibility to provide complete and accurate reference information on the form below; completing ALL fields. Failure to do so can result in CCSD being unable to verify the vendor’s past work, which may affect CCSD’s determination that the vendor is responsive and responsible. Preference may be given to references of similar size and scope. Do not list CCSD as a reference. CCSD reserves the right to consider past experience with the vendor.

Company/Entity:

Address:

Telephone: Fax:

Contact: Contact Email:

Provide a brief description of services/goods provided including dates.

Telephone: Fax:

Contact: Contact Email:

Provide a brief description

Telephone: Fax:

Contact: Contact Email:

Provide a brief description

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

GEORGIA SECURITY & IMMIGRATION COMPLIANCE ACT DOCUMENTS

Determine how to comply with the GA Security & Immigration Compliance Act

This section of the Agreement is related to the Georgia Security and Immigration Compliance Act, O.C.G.A.

§ 13-10-90 et seq. The chart below may assist the Contractor in determining which affidavit(s) must be provided as a provision of entering into this Agreement. If in doubt as to whether a document should be completed and submitted, it is recommended that the Contractor submit the information.

Does the

Contractor provide services?

Initial line 2(b) on the next page; complete the Affidavit of Exception and provide driver’s license as requested therein.

No affidavits are required. Employee(s) will perform the work.

Initial lines 2(a), 3 and 5 of the next page; and completion of the

Contractor Affidavit is required. Initial lines 2(a), 4 and 5 of the next page; completion of the

Contractor Affidavit and Subcontractor Affidavit are required.

STOP

Does the Contractor have employees and/or subcontractors or plan to hire employees and/or subcontractors to perform the work?

Subcontractor(s) will perform the work.

Both subcontractor(s) and employee(s) will perform the work.

YES

NO

NO

YES

STOP

STOP

STOP

Is the contract valued over $2,499?

YES

NO

Initial line 2(c) on the next page. complete the Affidavit of

Exception

STOP

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

GEORGIA SECURITY & IMMIGRATION COMPLIANCE ACT DOCUMENTS

GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT OF 2006, AS AMENDED BY

THE ILLEGAL IMMIGRATION REFORM ACT OF 2011, OCGA 13-10-90, ET SEQ.

TO ALL PROSPECTIVE CONTRACTORS:

If you are providing services to the Cobb County School District, this completed document, as well as the applicable Georgia Security and Immigration Compliance forms and affidavits referenced herein must be completed, signed, notarized, and submitted with your bid, proposal, quote, contract, or vendor registration.

1) The Cobb County School District shall comply with the Georgia Security and Immigration Compliance Act, as amended, O.C.G.A. § 13-10-90 et seq.

2) In order to ensure compliance with the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603 and the Georgia Security and Immigration Compliance Act of 2006, as amended by the Illegal Immigration Reform Act of 2011, O.C.G.A. § 13-10-90 et seq. (collectively the “Act”) the contractor (“Contractor”) MUST INITIAL the statement applicable to Contractor below:

(a) (Initial here) Contractor represents and warrants that Contractor has registered at https://e-verify.uscis.gov/enroll/ to verify information of all new employees in order to comply with the Act; is authorized to use and uses the federal authorization program; and will continue to use the authorization program throughout the contract period. Contractor further represents, warrants and agrees that it shall execute and return any and all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1-.01 et seq. in accordance with the terms thereof; (Complete and submit the Contractor Affidavit and Agreement); OR

(b) (Initial here) The Contractor is a sole proprietor with no employees, subcontractors, or sub-subcontractors, and it will not use or hire employees, subcontractors, or sub-subcontractors for any work performed for the District under the contract. This requires submission of a Georgia driver’s license or a license from an approved state. (Complete and submit the Affidavit of Exception); OR

(c) (Initial here) The Contractor will provide goods only to the District and will not render any services to the District. If your company provides goods along with ancillary services, such as maintenance, repairs, help desk support, customer support, technological support, or any other ancillary services, your company cannot file an Affidavit of Exception and must register with E-Verify. (Complete and submit the Affidavit of Exception); OR

(d) (Initial here) The Contractor is a foreign company and the work performed under the contract will be done in a foreign country by residents of that country. Contractor must comply with any other laws required to perform services in the United States, including but not limited to having an appropriate visa. (Complete and submit the Affidavit of Exception); OR

(e) (Initial here) The Contractor is an individual who is licensed pursuant to Official Code of Georgia Title 26 or Title 43, or by the State Bar of Georgia; whose license is in good standing, and the Contractor is the individual who will be performing the services under the contract. (Complete and submit the Affidavit of Exception)

3) (Initial here) Contractor will not employ or contract with any subcontractor in connection with a covered contract unless the subcontractor is registered, is authorized to use, and uses the federal work authorization program and provides Contractor with all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1- .01 et seq.

4) (Initial here) Contractor covenants and agrees that, if Contractor employs or contracts with any subcontractor in connection with the covered contract under the Act and DOL Rule 300-10-1-.02, then in such event Contractor will secure from each subcontractor at the time of the subcontract, the subcontractor’s name and address, the employer identification number/taxpayer identification number applicable to the subcontractor; the date the authorization to use the federal work authorization program was granted to subcontractor; the subcontractor’s attestation of the subcontractor’s compliance with the Act and Georgia Department of Labor Rule 300-10-1-.2.; and the subcontractor’s agreement not to contract with subcontractors unless the subcontractor is registered, authorized to use, and uses the federal work authorization program; and provides subcontractor with all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1-.01 et seq. (Complete and submit the Subcontractor Affidavit and Agreement)

5) (Initial here) Contractor agrees to provide the Cobb County School District with all affidavits of compliance as required by the Act and Georgia Department of Labor Rule 300-10-1-.02, 300-10-1-.03, 300-10-1-.07 and 300-10-1-.08 within five (5) business days of its receipt of any such documents.

Company Name:

https://e-verify.uscis.gov/enroll/

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

GEORGIA SECURITY & IMMIGRATION COMPLIANCE ACT DOCUMENTS

CONTRACTOR AFFIDAVIT PROVIDED PURSUANT TO O.C.G.A. § 13-10-91(b)(1)

The undersigned contractor ("Contractor") executes this Affidavit to comply with O.C.G.A § 13-10-91 related to any contract to which Contractor is a party that is subject to O.C.G.A. § 13-10-91 and hereby verifies its compliance with O.C.G.A. § 13-10-91, attesting as follows:

a) The Contractor has registered with, is authorized to use, and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program;

b) The Contractor will continue to use the federal work authorization program throughout the contract period, including any renewal or extension thereof;

c) The Contractor will notify public employer Cobb County School District in the event the Contractor ceases to utilize the federal work authorization program during the contract period, including renewals or extensions thereof;

d) The Contractor understands that ceasing to utilize the federal work authorization program constitutes a material breach of Contractor’s contract with Cobb County School District;

e) The Contractor will subcontract for the performance of services in satisfaction of such contract only with subcontractors who complete, sign, notarize, and present an affidavit to the Contractor with the information required by O.C.G.A. § 13-10-91(a), (b), and (c) prior to beginning the performance of services;

f) The Contractor acknowledges and agrees that this Affidavit shall be incorporated into any contract(s) subject to the provisions of O.C.G.A. § 13-10- 91 for the project listed below to which Contractor is a party after the date hereof without further action or consent by Contractor; and

g) Contractor acknowledges its responsibility to submit copies of any affidavits, drivers' licenses, and identification cards required pursuant to O.C.G.A. § 13-10-91 to public employer Cobb County School District within five (5) business days of receipt.

Federal Work Authorization User Identification Number (4 to 7 Digit Number)

Date of Authorization

Name of Contractor

Email Address

Name of Project/Contract

Telephone Number

Name of Public Employer Cobb County School District

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent of Contractor

Printed Name and Title of Authorized Officer or Agent

NOTARY INFORMATION

Subscribed and Sworn before me this the day of , 20 .

Notary Public Signature

My Commission Expires: ___________________________

Affix Notarial Seal Here

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

GEORGIA SECURITY & IMMIGRATION COMPLIANCE ACT DOCUMENTS

SUBCONTRACTOR AFFIDAVIT PURSUANT TO O.C.G.A. § 13-10-91(b)(3)

By executing this affidavit, the undersigned subcontractor (hereinafter the “Subcontractor”), which is engaged in the physical performance of services under a contract with ________________________________ (name of contractor) on behalf of public employer Cobb County School District, verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the Subcontractor has registered with, is authorized to use, and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the Subcontractor covenants that it will continue to use the federal work authorization program throughout the contract period, that the Subcontractor will contract for the physical performance of services in the performance of such contract only with sub-subcontractors who present an affidavit to the Subcontractor with the information required by O.C.G.A. § 13-10-91(b), and that the Subcontractor shall forward notice of receipt of any sub-subcontractor’s affidavit to the contractor and School District, together with a copy of such affidavit, within five (5) business days of its receipt of the same. If the Subcontractor receives notice that a sub-subcontractor has received an affidavit from any other contracted sub-subcontractor, the Subcontractor must forward, within five (5) business days of receipt, a copy of the notice, together with copies of such affidavits, to the contractor.

Subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number (4 to 7 Digit Number)

Date of Authorization

Name of Subcontractor

Email Address

Name of Project/Contract

Telephone Number

Name of Public Employer Cobb County School District

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent of Subcontractor

Printed Name and Title of Authorized Officer or Agent

Subscribed and Sworn before me this the day of , 20 .

My Commission Expires: ____________________________

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

GEORGIA SECURITY & IMMIGRATION COMPLIANCE ACT DOCUMENTS

AFFIDAVIT OF EXCEPTION PURSUANT TO O.C.G.A. § 13-10-91(b)(5) The undersigned, in connection with a proposed contract or subcontract with the Cobb County School District (the “School District”) for the physical performance of services in the State of Georgia (the “Contract”), hereby affirms and certifies under penalties of perjury that I am exempt from providing a Contractor Affidavit of E-Verify Compliance to the School District pursuant to O.C.G.A. § 13-10-91, as amended, for one of the following reasons:

(a) I am a sole proprietor with no employees, subcontractors, or sub-subcontractors, and I will not use or hire employees, subcontractors, or sub-subcontractors for any work performed for the School District;

In order to be exempt from compliance under the above exception, in addition to this affidavit you must provide a copy of your State of Georgia driver’s license. If you do not have a Georgia license, please see:

https://law.georgia.gov/sites/law.georgia.gov/files/related_files/site_page/List%20of%20States.pdf for a list of driver’s licenses from alternative states that can be submitted in lieu of a Georgia driver’s license.

If at any time hereafter I determine that I will need to hire employees to satisfy or complete the physical performance of services under the Contract, then before hiring any employees, I will:

(i.) Immediately notify the School District and all higher tier contractors (if any) in writing; and (ii.) Register with, participate in and use, a federal work authorization program operated by the United States Department of

Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986, P.L. 99-603, in accordance with the applicability provisions and deadlines established in O.C.G.A. § 13-10-90;

and

(iii.) Provide the School District with all affidavits required by O.C.G.A. § 13-10-90 et seq. and Georgia Department of Labor Rule 300-10-1-.01 et seq.

OR

(b) The Contractor will provide goods only to the District and will not render any services to the District. If your company provides goods along with ancillary services, such as maintenance, repairs, help desk support, customer support, technological support, or any other ancillary services, your company cannot file an Affidavit of Exception and must register with E-Verify;

OR

(c) The Contractor is a foreign company, and the work performed under the contract will be done in a foreign country by residents of that country;

OR

(d) The Contractor is an individual who is licensed pursuant to Official Code of Georgia Title 26 or Title 43, or by the State Bar of Georgia;

whose license is in good standing, and the Contractor is the individual who will be performing the services under the contract.

Print Company Name / Name of Sole Proprietor

Name of Project/Contract

BY: Signature of Authorized Officer/Agent of Company/Sole Proprietor Date

Sworn to before me this day of , 20

My Commission Expires: ____________________ https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Flaw.georgia.gov%2Fsites%2Flaw.georgia.gov%2Ffiles%2Frelated_files%2Fsite_page%2FList%2520of%2520States.pdf&data=05%7C01%7Cbarbara.bates%40cobbk12.org%7Ca952715535a94721667a08da59e2a3a3%7C2fce1dfb919f4938aab8c47f0fc9182d%7C0%7C0%7C637921127365270197%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=aCcBtrByQMYy7bHouMQdrsb1w%2BIwQ8qw2LF0v%2BVdi3g%3D&reserved=0

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

DISCLOSURE OF LOBBYING ACTIVITIES

BYRD ANTI-LOBBYING AMENDMENT

CONTRACTOR CERTIFICATION

Contractors who apply or bid for an award of $100,000 or more shall file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, officer or employee of Congress, or an employee of a Member of Congress in connection with obtaining any Federal contract, grant, or any other award covered by 31 U.S.C. § 1352. Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier, up to the recipient who in turn will forward the certification(s) to the awarding agency.

APPENDIX A, 44 C.F.R. PART 18 – CERTIFICATION REGARDING LOBBYING – REQUIRED FOR CONTRACTS

OVER $100,000

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

The Contractor certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. Chap. 38, Administrative Remedies for False Claims and Statements, apply to this certification and disclosure, if any.

MARIETTA, GEORGIA

PROCUREMENT SERVICES DEPARTMENT

DISCLOSURE OF LOBBYING ACTIVITIES

PROPOSER/CONTRACTOR:

SIGNATURE: __________________________________________________________

PRINT NAME & TITLE: __________________________________________________

COMPANY NAME: _____________________________________________________

DATE: _______________________________________________________________

MARIETTA, GEORGIA

CERTIFICATION REGARDING DEBARMENT OR SUSPENSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER

RESPONSIBILITY MATTERS

(a) By submission of this Certification, the individual or firm (“Contractor”) certifies, to the best of its knowledge and belief, that Contractor, Company, and its Principals:

• Are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

• Have not, within a three‐year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and

• Are not presently indicted for, or otherwise criminally or civilly charged by a governmental entity with commission of any of the offenses enumerated in subdivision (a)(1)(i)(B) of this provision.

• The Contractor has not, within a three‐year period preceding this offer, had one or more contracts terminated for default by any Federal agency.

"Principals," for the purposes of this certification, means officers; directors; partners; and, persons having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions).

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE

UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER SECTION 1001, TITLE 18, UNITED STATES

CODE.

(b) The Contractor shall provide immediate written notice to CCSD if, at any time prior to subcontract award, the Contractor learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

(c) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Contractor's responsibility. Failure

MARIETTA, GEORGIA

CERTIFICATION REGARDING DEBARMENT OR SUSPENSION

of the Contractor to furnish a certification or provide such additional information as requested by the CCSD may render the Contractor non-responsible.

(d) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of a Contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

(e) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making an award of the contract. If it is later determined that the Contractor knowingly rendered an erroneous certification, in addition to other available remedies CCSD may terminate the contract for default.

PROPOSER/CONTRACTOR:

SIGNATURE: __________________________________________________________

PRINT NAME & TITLE: __________________________________________________

COMPANY NAME: _____________________________________________________

DATE: _______________________________________________________________