C 08.0 Attachment 1 PWS TRFB 1EA BPS-16 Mast Thermal Spr Redacted.pdf

PREFORMANCE WORK

STATEMENT (PWS)

REV-2 DTD 4/7/2022

CHECK ALL BELOW THAT APPLY:

HIGH RISK JUSTIFICATION: Service supports the restoration of one SSN774 Class variant of the AN/BPS-16 Radar Mast Sub-Assembly that directly affects the successful completion of the SSN 775 availability at Portsmouth Naval Shipyard. Delays to timely procurement and accomplishment of the service directly affect availability schedules and potential to delay the underway of a submarine unit.

SUBSAFE

DSS/SOC

LOCATION OF WORK IS WITHIN AN AREA THAT REQUIRES NAVSEA REVIEW

JML #: N/A - LDS System @ TRF-B DD2276 #: (Request for Contractual Procurement (RCP) required for services over $2500 or services with terms and conditions.) – Received from Funds Administrator Ship/Activity: TRF BANGOR RADAR DEPOT Title: AN/BPS-16 RADAR MAST THERMAL SPRAY RESTORATION SERVICES Place of Performance: Vendor Facility - CONUS Period of Performance: From 22 APR 2022 to 17 June 2022

1. BACKGROUND

1.1 The Trident Refit Facility Bangor (TRF-B) Radar Depot performs restoration of SSN774 Class, SSN 21 Class, and SSBN 726 Class variants of the AN/BPS-16 radar mast sub-assembly for the US Navy. Each radar mast sub-assembly is comprised of three mast tubes: one (1EA) Outer Housing, one (1EA) Radar Mast, and one (1EA) Rotary Tube. The mast tubes must maintain their SUBSAFE/Level 1 certifications such that TRF-B, the “SUBSAFE Certifying Activity”, will oversight the repair process required by contract for SUBSAFE/Level 1 work performed by contractors not previously certified to perform SUBSAFE work by NAVSEA. During restoration of radar mast sub-assemblies, the outer surfaces of each mast tube requires surface finish restoration using NAVSEA certified thermal spray deposition processes. Reference 2.1, Enclosure (2), paragraph 1 specifies refurbishment of the outer surfaces of the three individual mast tubes of the AN/BPS-16 mast sub-assembly using thermal spray processes identified in Reference 2.2.

1.2 One AN/BPS-16 mast sub-assembly, a total of three (3EA) radar mast tubes require refurbishment by thermal spray. The mast sub-assembly and its three associated mast tubes are listed in paragraph 5.3.1.

2. REFERENCES

2.1 TRF Bangor Engineering Memorandum 410/017M-19 Rev-H, SUBSAFE; Flame Spray BPS- 16 Mast Components by Non-SUBSAFE Qualified Contractor

2.2 NAVSEA T9074-AA-GIB-010/1687 dtd 12 JUN 2017; Thermal Spray Process for Naval Ship

Machinery and Non-Skid Applications

2.3. MIL-STD-1687A; Thermal Spray Processes for Naval Ship Machinery Applications, includes Notice 2 dtd 12 JUN 2017; Notice of Cancellation

2.4 NAVSEA T9074-AS-GIB-010/271 Rev-1 dtd 11 SEP 2014; Requirements for Non-Destructive Test Methods

2.5 ASNT SNT-TC-1A 2020 Edition, Personnel Qualification and Certification in Nondestructive Testing

3. WORK REQUIREMENTS

3.1 Contractor Work Requirements:

3.1.1 For consideration under this contract, the contractor’s thermal spray facility, quality assurance program, and the thermal spray procedures used in support of these services shall be previously NAVSEA certified in accordance with (IAW) paragraphs 5.1 and 5.2 of Reference 2.2 and documented proof thereof shall be provided at solicitation with their proposal for technical review and consideration.

3.1.1.1 Reference 2.3 is the previous approved military specification for thermal spray processes for naval ship machinery applications, which was superseded by Reference 2.2 as detailed in “Notice 2” of Reference 2.3. Contractors who were previously NAVSEA certified to perform machinery restorative thermal spray processes, along with any previously approved machinery restorative thermal spray procedures under Reference 2.3 are satisfactory for performance and contract award per NAVSEA Thermal Spray In-Service Engineering Agent (ISEA) representatives via email communication.

3.1.2 The contractor shall not use any sub-contractor to perform any work associated with this service, the only exception permitted is the use of a sub-contractor to perform nondestructive liquid dye penetrant testing (NDT PT). When subcontracting NDT PT, all work shall be conducted at the facility of, and under direct supervision of, the primary contractor. All handling of the components (e.g., lifting, positioning, and/or transporting) shall be performed by the primary contractor.

3.1.3 For consideration under this contract, the contractor, or sub-contractor if used, must meet all NAVSEA requirements for NDT PT, to include Reference 2.4 and Reference 2.5. Prior to consideration for award, the contractor, or sub-contractor if used, will be evaluated by the NAVSEA activity, TRF-B, to the requirements of Reference 2.4 and Reference 2.5. For this service the TRF-B nondestructive testing division, code 630, NDT Level III Examiner will perform the review.

3.1.3.1 The contractor, or sub-contractor if used, shall provide the following documentation at solicitation with the proposal for technical review and consideration:

a. Contractor’s/Sub-Contractor’s Written Practice.

b. NDT LP procedure meeting requirements of Reference 2.4 Chapter 5.

c. NDT Personnel Certification Records meeting requirements of Reference 2.4 paragraphs

1.6, 1.6.2.1, 1.6.4 and 1.6.8, as well as Reference 2.5 paragraph 9.4.

d. Summary of the Contractor’s/Sub-Contractor’s NDT surveillance program.

e. Any other documentation regarding the NDT program when requested.

3.1.3.2 As determined by the TRF-B nondestructive testing division, code 630, NDT Level III Examiner the conduct of an initial, and potential follow-on, site visits may be required to verify compliance with the requirements of Reference 2.4 and Reference 2.5. The contractor shall permit TRF-B nondestructive testing division, code 630, personnel, access to the work site(s) to observe the performance of the NDT PT to verify NDT PT written practice and NDT PT surveillances comply with Reference 2.4 and Reference 2.5 requirements.

3.1.3.2.1 The contractor shall provide a minimum of seven workdays notification to the TRF-B COR and NDT Level III Examiner points-of-contact listed in paragraph 9 prior to conduct of any and all NDT PT. Notification is required to enable sufficient time for travel arrangements for the site visits for NDT PT performance review(s).

3.1.3.2.2 Initial, and potential follow-on, site visits for NDT PT performance review may not excessively impede or delay the contractor, or subcontractor, such to prevent meeting delivery milestone dates or otherwise extend the period of performance of the contract.

3.1.3.2.3 The TRF-B nondestructive testing division, code 630, personnel performing the NDT PT performance review may initiate a stoppage of follow-on work from the NDT PT, for not more than forty eight hours, to enable identifying and communicating potential NDT PT certification discrepancies. Communication of any noted NDT PT performance discrepancies shall be made to the TRF-B COR and Planning points-of-contact listed in paragraph 9 not later than twenty four hours of discrepancy discovery.

3.1.4 Upon award of contract and prior to commencement of work on SUBSAFE AN/BPS-16 radar mast tubes, the contractor shall permit the “qualified SUBSAFE activity” representatives, TRF-B, access to their work site(s) to verify compliance with SUBSAFE requirements through an initial and follow-on periodic site visits IAW Reference 2.1 Enclosure (1) paragraphs 3 through 3.f.

3.1.4.1 When TRF-B has conducted a site visit of the contractor’s facility for similar SUBSAFE maintenance within the past 24 months from the contract award, follow-on site visits are required prior to the conclusion of the 24 months periodicity requirement IAW Reference 2.1 Enclosure (1) paragraph 3.a.

3.1.5 Upon award of contract and prior to commencement of any work on SUBSAFE AN/BPS-16 radar mast tubes, the contractor shall enter into a Memorandum of Agreement (MOA) with TRF-B to assign responsibilities and actions required by both parties for the conduct of SUBSAFE work under the oversight of TRF-B IAW Reference 2.1 Enclosure (1) paragraph

2. The MOA will not modify or change any requirement imposed herein by the Statement of Work or the awarded contract.

3.1.6 Reference 2.2 paragraph 3.1.3 requires written records for AN/BPS-16 radar mast tubes in the accomplishment of thermal spray repairs, which are satisfied by Reference 2.1 Enclosure (5);

Thermal Spray Job Control Record (TSJCR). The contractor shall provide a completed TSJCR as CDRL item A001 for each mast tube. If the TSJCR is lost or illegible upon receipt, contact the TRF-B COR and planning points-of-contact listed for a replacement.

3.1.6.1 Reference 2.1 Enclosure (5) provides a “blank” sample of the TSJCR, and includes instructions on the use of, and completion of, the TSJCR form. Data required to be entered on the TSJCR by the contractor are identified by “(Spray Activity)” and “(Spray Activity) Quality Assurance (QA)”.

3.1.6.2 The Contractor shall generate and assign a unique thermal spray serial number for each AN/BPS-16 radar mast tube IAW Reference 2.1 Enclosure (5). The contractor shall communicate the unique thermal spray serial numbers to the TRF-B COR and planning points-of-contact listed in paragraph 9 listed no later than three workdays following contract award such to provide time for the application of the thermal spray serial number markings by TRF-B prior to shipping AN/BPS-16 radar mast tubes to the contractor.

3.1.7 The contractor shall use and complete the Objective Quality Evidence (OQE) records, Reference 2.1 applicable Enclosure (6), (7), or (8), during the refurbishment of the AN/BPS- 16 radar mast tubes IAW Reference 2.1 paragraph 2. The contractor shall provide the completed OQE Record, Reference 2.1 applicable Enclosures (6), (7), or (8), as CDRL item A002 for each mast tube. If an OQE record is lost or illegible upon receipt, contact the TRF- B COR and Planning points-of-contact listed in paragraph 9 for a replacement.

3.1.8 The contractor shall conduct an inspection upon receipt of AN/BPS-16 radar mast tubes prior to commencement of work. The inspection shall confirm receipt of the AN/BPS-16 radar mast tubes with the supplied documentation package. The AN/BPS-16 radar mast tube documentation package is comprised of the following:

3.1.8.1 Material Identification (ID) / Control Tag, QA Form 2 – The contractor shall validate the inscribed markings on the AN/BPS-16 radar mast tube correlate to the recorded data in the “MIC NO/SERIAL NO” field of the QA Form 2 attached to the AN/BPS-16 radar mast tube.

If a QA Form 2 is lost or illegible upon receipt of an AN/BPS-16 radar mast tube, notification within 24 hours, by telephone and email message to the TRF-B COR and planning points-of-contact listed in paragraph 9 is required.

3.1.8.1.1 The QA Form 2 shall remain legible and remain physically attached to the AN/BPS-16 radar mast tube at all times during repair and refurbishment processes and upon completion of refurbishment the QA Form 2 shall be returned to TRF-B physically attached to the AN/BPS-16 radar mast tube.

3.1.8.1.2 The contractor shall only remove the QA Form 2 temporarily when it is required to preclude damage during refurbishment processes. When the QA Form 2 requires removal prior to a potentially damaging operation, the QA Form 2 shall be stored in the vicinity of the AN/BPS-16 radar mast tube such that it cannot be misplaced or damaged, and without delay reattached to the AN/BPS-16 radar mast tube upon the immediate cessation of each potentially damaging process. The contractor shall not make any entry on the QA Form 2; its purpose is for traceability and material control requirements by TRF-B instructions.

3.1.8.2 Maintenance Certification Record/Re-Entry Control, QA Form 9/QA Form 10 (REC) - The contractor shall validate the “CWP/REC SERIAL NO” recorded in data field “4.” of the REC correlates to the recorded data in the “CWP SER. NO.” field of the QA Form 2 attached to the AN/BPS-16 radar mast tube(s).

3.1.8.2.1 The REC shall remain legible, and accompany the AN/BPS-16 radar mast tube(s) at all times during repair and refurbishment processes. The REC shall be returned to TRF-B with the AN/BPS-16 radar mast tube(s) upon completion of refurbishment. If a REC is lost or illegible upon receipt of AN/BPS-16 radar mast tube(s), notification within 24 hours by telephone and email message to the TRF-B COR and planning points-of-contact listed in paragraph 9 is required. The contractor shall not make any entry on the REC; its purpose is for SUBSAFE work authorization and control requirements by TRF-B instructions.

3.1.8.3 Thermal Spray Job Control Record (TSJCR) – The contractor shall validate the inscribed markings on the AN/BPS-16 radar mast tube correlate to the recorded data in the “MIC NO.”

field in Section I of the TSJCR that accompanies the AN/BPS-16 radar mast tube.

3.1.8.4 Objective Quality Evidence (OQE) record – The contractor shall verify the OQE record, Reference 2.1 applicable Enclosures (6), (7), or (8), is enclosed with the AN/BPS-16 radar mast tube.

3.1.9 The contractor shall refurbish the outer surfaces of AN/BPS-16 radar mast tubes using thermal spray deposition processes and process controls IAW References 2.1 and Reference 2.2.

3.1.9.1 Pre-thermal spray machining of the AN/BPS-16 radar mast tubes shall be performed IAW paragraph 4.4.2 of Reference 2.2.

3.1.9.1.1 The AN/BPS-16 radar mast tube sketches, Enclosure (3) Sheets 1 through 3 of Reference 2.1, provide additional process limits and requirements in the “Repair Notes” and “Drawing Notes” blocks that shall be adhered to during pre-thermal spray machining processes.

3.1.9.1.2 The base material and yield strength properties of AN/BPS-16 radar mast tubes are provided in paragraph 5 of Enclosure (2) of Reference 2.1.

3.1.9.2 Nondestructive testing PT meeting the requirements of Reference 2.4 shall be conducted upon completion of pre-thermal spray machining operations.

3.1.9.3 Reference 2.1 Enclosure (2) paragraph 6.a requires solvent cleaning be performed IAW paragraph 4.4.1. of Reference 2.2.

3.1.9.4 Reference 2.1 Enclosure (2) paragraph 6.a requires abrasive blasting be performed IAW paragraph 4.4.2.5 of Reference 2.2.

3.1.9.5. Reference 2.1 Enclosure (2) paragraph 3 requires the type of thermal spray as plasma spray using a Monel (NiCu) bond coat and Alumina-Titania finish coat, or a Nickel-Aluminum- Molybdenum (NiAlMo) bond coat with Alumina-Titania finish coat.

3.1.9.5.1 Reference 2.1 Enclosure (2) paragraph 4 specifies the maximum thickness for the thermal spray Monel (NiCu) or Nickel-Aluminum-Molybdenum (NiAlMo) bond coat and Alumina-Titania finish coat.

3.1.9.6 Reference 2.1 Enclosure (2) paragraph 6.b.(1) through 6.b.(3)(i) specifies the tolerance for outside diameter and surface finish of the thermal spray restoration of AN/BPS-16 radar mast tubes.

3.1.9.7 Reference 2.1 Enclosure (2) paragraph 7 requires inspection of thermal sprayed coatings IAW paragraph 3.5.2.1 of Reference 2.2.

3.1.10 The contractor shall ensure cleanliness of the AN/BPS-16 radar mast tubes prior to their return to TRFB. Mast tubes shall be in a similar state of cleanliness as when received from TRFB, and shall be free of industrial residue and debris from the thermal spray processes.

3.1.11 During the TRF-B review of each AN/BPS-16 radar mast tube’s submitted documentation of CDRL items A001 and A002, if TRF-B determines correction/changes are required to meet the requirements of Reference 2.1 for records retention, the contractor shall make corrections/changes within 3 workdays of notification by email message.

3.1.12 The contractor shall provide weekly progress reports, no later than close of business on every Wednesday, to the TRF-B COR and Planning points-of-contact listed in paragraph 9 concerning the work in process at the contractor’s facility under this contract. The content of the report shall express completion percentages for each radar mast tube, completion projections for the following week, and proposed dates for performance of NDT PT.

3.1.12.1 The contractor shall identify any discrepancies discovered during receipt of, or work in process of, AN/BPS-16 radar mast tubes. Communication of the discrepancies shall be made to the TRF-B COR and Planning points-of-contact listed in paragraph 9 not later than twenty four hours of discrepancy discovery.

3.2. Government (TRF-B) Work Requirements:

3.2.1 TRF-B nondestructive testing division, code 630, NDT Level III Examiner will evaluate the contractor’s, or sub-contractor’s if used, submitted records in accordance with paragraph

3.1.3 to ensure compliance with all NAVSEA requirements for NDT PT, to include Reference 2.4 and Reference 2.5.

3.2.1.1 TRF-B nondestructive testing division, code 630, NDT Level III Examiner may determine the need to assess the conduct of the NDT PT by the contractor, or subcontractor, to verify their compliance with the requirements of Reference 2.4 and Reference 2.5. This assessment may be performed by an initial and potential follow-on, site visit(s) by TRF-B nondestructive testing division, code 630, personnel.

3.2.1.1 Site visits of the contractor’s facility for the initial assessment, and potential follow-on review, will be coordinated by the TRF-B COR and NDT Level III Examiner points-of-contact listed in paragraph 9 with input from the contractor concerning the period of performance (dates and schedule) of the site visits.

3.2.1.2 The funding and the arrangement of travel of the TRF-B employees for the purpose of the site visit(s) is the responsibility of TRF-B.

3.2.2 TRF-B engineering division, code 410, and SUBSAFE Program division, code 06, personnel will conduct the initial assessment, and any required forthwith every twenty-four months, to verify the contractor’s compliance with SUBSAFE requirements through an initial and follow-on periodic site visits IAW Reference 2.1 Enclosure (1) paragraphs 3 through 3.f.

3.2.2.1 Site visits of the contractor’s facility for the initial assessment, or twenty-four month follow-on review, will be coordinated by the TRF-B COR, Engineering, and SUBSAFE Program points-of-contact listed in paragraph 9 with input from the contractor concerning the period of performance (dates and schedule) of the site visits.

3.2.2.2 The funding and the arrangement of travel of the TRF-B employees for the purpose of the site visit(s) is the responsibility of TRF-B.

3.2.3 Upon award of contract TRF-B will enter into a Memorandum of Agreement (MOA) with the contractor to assign responsibilities and actions required by both parties for the conduct of SUBSAFE work under the oversight of TRF-B IAW Reference 2.1 Enclosure (1) paragraph 2.

3.2.4 For each AN/BPS-16 radar mast tube, TRF-B will provide the TSJCR form, Reference 2.1 Enclosure (5), within the shipping crate, which is pre-filled by TRF-B IAW Reference 2.1 Enclosure (5).

3.2.4.1 TRF-B will apply the unique thermal spray serial number to each AN/BPS-16 radar mast tube IAW Reference 2.1 Enclosure (1) paragraph 4.c. in the specified area IAW Reference 2.1 Enclosure (3).

3.2.5 TRF-B will provide the OQE Record, Reference 2.1 applicable Enclosures (6), (7), or (8), with each AN/BPS-16 radar mast tube, within the shipping crate, for use during refurbishment.

3.2.6 TRF-B will provide the REC, within the shipping crate, prior to shipping AN/BPS-16 radar mast tubes to the contractor.

3.2.7 TRF-B will physically attach the Material Identification (ID) / Control Tag, QA Form 2, to each AN/BPS-16 radar mast tube prior to shipping the mast tube to the contractor.

3.2.8 A review of each AN/BPS-16 radar mast tube’s submitted CDRL items A001 and A002 documentation will be performed by TRF-B engineering division, code 413, and TRF-B material certification branch, code 612, prior to acceptance and retention.

3.2.8.1 During review, if TRF-B determines changes are required to meet the record requirements of Reference 2.1 notification to the contractor will be made via the COR within 5 workdays of receipt of each AN/BPS-16 radar mast tube’s CDRL item A001 and CDRL item A002.

3.2.9 TRF-B shall perform a technical receipt inspection of each restored AN/BPS-16 radar mast tube upon receipt from the contractor IAW Reference 2.1 Enclosure (1) paragraph 8 through 8.d.

3.2.9.1 The completion of inspections, review of documentation, and acceptability of the contractor’s services will be completed within 10 workdays from the date of receipt of restored AN/BPS- 16 radar mast tubes.

4. CONTRACTOR FURNISHED ITEMS – PROPERTY, MATERIAL, EQUIPMENT,

SERVICES

4.1 The contractor shall furnish the following deliverable items:

4.2.1 Completed TSJCR, Reference 2.1 Enclosure (5), shall be provided for each AN/BPS-16 radar mast tube IAW CDRL item A001. In addition, the “wet ink” original document shall be returned to TRF-B within the shipping crate along with the AN/BPS-16 radar mast tubes.

4.2.2 Completed OQE record, Reference 2.1 applicable Enclosure (6), (7), or (8) shall be provided for each AN/BPS-16 radar mast tube IAW CDRL item A002. In addition, the “wet ink” original document shall be returned to TRF-B within the shipping crate along with the AN/BPS-16 radar mast tubes.

5. GOVERNMENT-FURNISHED ITEMS – PROPERTY, MATERIAL,

EQUIPMENT, SERVICES

5.1 Original acquisition value of material: $541,597.63 (FY22 NSN costs itemized below)

1EA SSN 774 Class AN/BPS-16 Radar Mast Sub Assembly:

P/N 1978730 Rotary Tube NSN 5840-01-610-0381 $215,160.63/EA (FY22 cost) P/N 1978732 Inner Mast NSN 5985-01-633-7512 $121,011.00/EA (FY22 cost) P/N 1980470 Outer Housing NSN 5985-01-633-7504 $205,426.00/EA (FY22 cost)

5.2 Location of GFP:

TRF-B, BLDG 7086, Shop 67R

5.3 Manufacturer, model # and type include serial number(s):

5.3.1 AN/BPS-16 mast sub-assembly variant 1978837-4 from JCN 00104BPS60046 consisting of the following mast tubes:

1EA Outer Housing, CAGE 03956, PN 1980470, IT 9 of DWG 4800091/PL480091-4, Serial Number: NCG08126-011 QQ 1EA Rotary Tube, CAGE 03956, PN 1978730, IT 7 of DWG 4800091/PL4800091-4, Serial

Number: 30370-002-2 1EA Inner Mast, CAGE 03956, PN 1978732, IT 8 of DWG 4800091/PL4800091-4, Serial

Number: KMD08126-002 QQ

5.4 Government provided or contractor pickup: Government Provided

6. QUALITY ASSURANCE SURVEILLANCE PLAN

6.1 TRF-B COR will evaluate the contractor’s progress via the weekly progress reports in accordance with paragraph 3.1.12.

6.1.1 IAW paragraph 3.1.4 to 3.1.4.1 TRF-B representatives verifies the contractor’s compliance with SUBSAFE requirements through an initial and follow-on twenty-four month periodic site visits of the contractor’s facility and quality control program.

6.1.2 IAW paragraph 3.1.3.2 to 3.1.3.2.3 TRF-B nondestructive testing division, code 630, NDT Level III Examiner conducts an initial, and potential follow-on, site visits to verify the NDT PT performance complies with the requirements of Reference 2.4 and Reference 2.5.

6.1.3 When the COR has concerns as to performance, delays, or discrepancies concerning the work in process at the contractor’s facility under this contract email communication to the contracting officer, contracting specialist, TRF-B Planning, and TRF-B Engineering points-of-contact listed in paragraph 9 will be made.

6.1.4 For this service, and during administration of this contract, technical matters outside the scope of the COR’s area of responsibility, i.e., engineering requirements, non-destructive contractor shall provide the shipment tracking identification data to the TRF-B COR within forty eight hours of shipping carrier pick-up from the contractor.

FOB Destination:

TRIDENT Refit Facility Bangor 7000 Finback Circle BLDG 7000 Door 12 Receiving Silverdale, WA 98315-7000 ATTN: Shop 67R Supervisor, PH:

11.2.2.1 To assist with determining return freight shipping costs the dimensions and maximum weight of the loaded shipping crate is provided below:

SSN 774 Class AN/BPS-16 radar mast set of three tubes:

Shipping Crate Dimensions: 34”W x 26”H x 116”LG Shipping Crate Weight: 1450 lbs (approximately)

11.2.2.2 Delivery to TRF-B, within the confines of US Naval Base Kitsap Bangor (NBK-Bangor), requires the delivery carrier driver(s) to have documented proof of US citizenship on their person (no photocopies permitted) to obtain temporary badging at the NBK-Bangor Pass & ID office. Alternatively, the delivery carrier driver(s) may possess pre-issued NBK-Bangor/TRF-B badging credentials to enable entry to NBK-Bangor and TRF-B.

11.2.2.3 NBK-Bangor Pass & ID office and commercial entry gate operational schedule is

Monday through Friday 06:30 to 15:00 and delivery must be made during this period.

Requirements Originator TRFB C/440 Supervisor Digital Signature & Date: _______________________________________

Cog Tech Code Review TRFB C/410 Div-Head Digital Signature & Date: _______________________________________