Freetown-Lakeville Regional School District

QUOTE REQUEST

RUBBISH REMOVAL / RECYCLING SERVICES

AWARDING AUTHORITY Freetown-Lakeville Regional School District

98 Howland Road Lakeville, MA 02347 508-923-2000

SCHEDULE OF DATES

Quote Request: Thursday, April 16, 2026

Specifications Available: Thursday, April 16, 2026

Online at www.freelake.org click under District, then Financial Operations

Quote Receipt: Superintendent Office

Lakeville, MA 02347 Hardcopy or email to:

jhiggins@freelake.org Copy to:

ggoodwin@freelake.org

May 8, 2026 @ 11:00 a.m.

mailto:ggoodwin@freelake.org

Table of Contents

1. Quote Request pg 3

2. Massachusetts Weekly Certified Payroll Report Form pg 6

3. Weekly Payroll Records Report & Statement of Compliance pg 7

4. Prevailing Wage Rates – Freetown pg 8

5. Prevailing Wage Rates – Lakeville pg 17

6. Quote Proposal pg 26

7. Reference Form pg 28

8. Agreement pg 29

FREETOWN-LAKEVILLE REGIONAL SCHOOL COMMITTEE

Lakeville MA 02347

QUOTE REQUEST

FOR RUBBISH REMOVAL / RECYCLING SERVICES

April 16, 2026

Quotes are being solicited to provide the Freetown-Lakeville Regional School District Committee with trash disposal and recycling services for the District Facilities for fiscal year July 1, 2026, through June 30, 2029. The estimated monthly amount of refuse generated by each location is between one and one-half (1½) to four (4) tons. It is estimated that thirty percent (30%) of recyclable paper will be placed into other containers and not into the general waste stream, as the Regional School District participates in a paper recycling program. Attention is called to the attached prevailing wage rates. Quotes shall be made based on the Prevailing Wage Schedule as determined by the state under the provisions of the Massachusetts General Laws, Chapter 149, Sections 26 to 27H.

SCOPE OF WORK

The container requirements for each facility are as follows:

REQUIREMENTS:

Apponequet Regional High School 1 ea. 35 yd hydraulic liquid-tight trash compactor 100 Howland Road 1 ea. 10 yd cardboard recycle Lakeville, MA 02347 6 ea. Heavy-duty plastic style recycle totes

Freetown-Lakeville Middle School 1 ea. 35 yd hydraulic liquid-tight trash compactor 96 Howland Road 1 ea.10 yd cardboard recycle Lakeville, MA 02347 6 ea. Heavy-duty plastic style recycle totes

George R. Austin Intermediate School 1 ea. 35 yd hydraulic liquid-tight trash compactor 112 Howland Road 1 ea. 10 yd cardboard recycle Lakeville, MA 02347 6 ea. Heavy-duty plastic style recycle totes

Assawompset Elementary School 1 ea. 35 yd hydraulic liquid-tight trash compactor 232 Main Street 1 ea. 10 yd cardboard recycle Lakeville, MA 02347 6 ea. Heavy-duty plastic style recycle totes

Freetown Elementary School 1 ea. 35 yd hydraulic liquid-tight trash compactor 43 Bullock Road, 1 ea. 10 yd cardboard recycle East Freetown, MA 02717 6 ea. Heavy-duty plastic style recycle totes

Maintenance Barn @ rear of High School 1 ea. 10 yd dumpster

a. All containers are to be delivered to the respective sites at the start of the contract (July 1st) in new or “like-new” condition and liquid-tight. The owner reserves the right to inspect and approve the equipment at installation and subsequent contract renewal years. Contractor will install replacement unit(s) if the equipment does not meet this requirement.

b. Trash compactors will incorporate a pressure gauge to indicate ullage and unit full status at a glance.

Compactors are expected to perform to the manufacturer’s compaction rate specifications.

Compactors should be able to hold a minimum of 6.5 tons of trash before an empty call is required and should be able to routinely compact approximately 8 tons.

c. School district personnel will monitor gauge(s) and will call the contractor to empty the compactor when full. It is understood that the compactor will be picked up within 1 - 2 days of the empty request. Upon pickup, the compactor will be emptied and returned to service on the same day.

d. With the exception of large open-top style dumpsters, all trash compactors, dumpsters, and cardboard containers must have the ability to be secured to prevent unauthorized use.

e. All trash and cardboard containers are to have the ability to be loaded from the front or side without lifting trash above the head.

f. Contractor is responsible for all repairs and maintenance, appearance, and sanitary condition of all containers. Annually, at the anniversary of the contract start date, all containers will be removed from the respective sites to be serviced and reconditioned for a total of two reconditioning services during the duration of the contract. Scheduling of this service is to be coordinated with the school district Director of Facilities or designee.

Entire unit, including pump(s), hydraulic ram, hoses, fittings, gaskets, hardware, fit and finish (paint), etc., will be inspected and serviced as necessary. Containers will be washed and sanitized at the end of service and before they are returned to operation at the site. This regimen will commence at the start of the contract and be scheduled annually with the Director of Facilities during the second and third week of August. At the contractors’ expense, open-top dumpsters are to be placed at the respective site to receive daily rubbish during the period that the compactor receives the preventative maintenance service.

g. General maintenance and emergency repairs of containers are the sole responsibility of the contractor and must be done in a timely manner for the safety and continuity of school operations. Contractor to make repairs within twenty-four hours of service call. At no time is rubbish allowed to collect at a facility. If the repairs can’t be completed in a reasonable amount of time, dumpsters will be provided at no charge to the customer. The temporary dumpster will remain on site until the repairs are completed and the container is put back in service.

h. Cardboard and 10 yd. Trash dumpsters located at school facilities will be emptied bi-weekly ( 2x/ month ). It is the responsibility of the contractor to pick up any fly-away debris when emptying dumpsters.

i. It is understood that the Freetown – Lakeville Regional Schools can telephone to request additional pick-ups at any of the locations due to infrequent, increased trash loads from events or projects.

These additional rates will be billed at the normal rate(s) listed in the bid.

j. Containers will be properly labeled and conform to both the Town of Lakeville and Town of Freetown Town Ordinances and Boards of Health regulations.

k. Drivers will adhere to the posted speed limits and use extreme caution while driving on school grounds. Failure to follow these rules may result in contract termination.

l. Contractor may be requested to provide infrequent delivery and pickup service of a 30-yard roll-off container for large and/or bulky items or construction/project debris.

m.Contractor is responsible, throughout the duration of the contract, to obtain and maintain any permits and adhere to the restrictions and requirements relative to the collection and hauling of trash and recyclables in the Towns of Freetown and Lakeville, respectively. Annually, copies of the permit(s) are to be sent to the Office of the Superintendent, c/o G. Goodwin, Director of Facilities, at 98 Howland Road, Lakeville, MA 02347.

n. Compactors should be washed/deodorized quarterly, during contract, and as needed if the presence of odor is overwhelming.

The dumpsters and compactors will be placed at the following locations at each site.

1. Apponequet Regional High School 100 Howland Road, Lakeville, MA 02347 *Containers to be located next to the kitchen receiving area.

2. Freetown – Lakeville Middle School 96 Howland Road, Lakeville, MA 02347 *Containers to be located adjacent to the loading dock to the rear of the building.

3. George R. Austin Intermediate School

112 Howland Road, Lakeville, MA 02347 *Containers to be located on the left side of the building near the wood line.

4. Maintenance Barn (Rear of High School) 100 Howland Road, Lakeville, MA 02347 *10 yd trash dumpster to be located at the west gable end of the barn facing the tennis courts.

5. Assawompset Elementary School

232 Main Street, Lakeville, MA *Containers to be located in the rear of the building by the kitchen.

6. Freetown Elementary School 43 Bullock Road, East Freetown, MA *Containers to be located in the rear of the building, to the right of the boiler plant overhead door

Plastic-style, “single stream” Recycle Containers:

Contractor will provide a set of six (6), heavy-duty plastic bins per school facility to be used for paper and plastic bottle single-stream recycling. Bins are to be 50 – 65 gallon capacity and clearly marked “RECYCLE”. Bins will have wheels for portability and have a flip-top cover. Bins will remain the property of the contractor and will be returned at the end of the contract. Owner assumes no responsibility for damage from normal use and/or trash inadvertently placed into plastic recycling bins.

Recycle bins will be picked up at each facility bi-monthly or two (2) times per month. Bin pick-up schedule to be set with the facilities manager at the start of the contract.

Contractor is responsible for general maintenance and refurbishing recycling bins as needed and at least annually during the summer months of July or August.

QUOTE INFORMATION

For questions relative to the site, quote or draft contract document, or to arrange a visit to the site, please contact Greg Goodwin, Director of Facilities, by e-mail at ggoodwin@freelake.org. Please copy John Higgins jhiggins@freelake.org on all correspondence. All questions relating to this quote must be submitted no later than April 27, 2026 Questions and answers will be sent via e-mail by May 1, 2026 to those quoters who have received a copy of this quote request and have provided the District with an email address.

A successful quoter must furnish Insurance Certificates meeting Freetown-Lakeville Regional School District requirements.

The issuance of specifications and subsequent receipt of quotes does not bind the Freetown-Lakeville Regional School District to an award decision, but does permit the Freetown-Lakeville Regional School District to participate in the collective purchasing process, if it desires to do so.

Quotes emailed or provided in hard copy and marked “RUBBISH REMOVAL/RECYCLING” will be received at the Office of the Superintendent of Schools, 98 Howland Road, Lakeville, MA 02347, until May 8, 2026 at 11:00 AM.

The District reserves the right to waive any informalities in the quotes, to accept or reject any or all quotes, and/or to call for new quotes, if it is deemed to be in the best interest of the Freetown-Lakeville Regional School District to do so. The District reserves the right to request, and the contractor will agree to supply, at contract prices, all trash removal needs, whether more or less than the estimated quantities listed herein.

For the Freetown - Lakeville Regional School District

John Higgins Director of Finance and Operations mailto:jcournoyer@freelake.org

FREETOWN-LAKEVILLE REGIONAL SCHOOL COMMITTEE

Lakeville MA 02347

QUOTE REQUEST FOR RUBBISH REMOVAL / RECYCLING SERVICES

To: Freetown - Lakeville Regional School District

The undersigned proposes to supply the rubbish removal and recycling requirements in conformity with the foregoing specifications for the following.

*Quoters will base trash compactor pick-up/ dump run frequencies on each compactor holding 7.5 tons of trash before needing to be emptied. (Weight of unit not included in total tonnage) and the District is disposing of approximately 160 tons of the total volume of trash annually into compactors. Prices are set for the duration of the contract.

▪ Annual (1 yr.) service fee 10 yd. TRASH dumpster per unit (landfill fees included) 1 unit total price _______________

▪ Annual (1 yr.) service fee 10 yd. CARDBOARD dumpster per unit (landfill fees included) 5 dumpsters total price _______________

▪ Annual (1 yr.) lease of 35 yd. compactors 5 compactors total price _______________

▪ Compactor container pick-up/ dump fee each per unit price _______________

▪ Price per ton land-fill trash fee (compactor and open top container) _______________

▪ Annual (1 yr.) service fee plastic recycle bin per facility (set of 6 ea.)

5 Sets of 6 bins total price_______________

▪ 30 yd. open-top roll-off container drop/ pick-up/ dump fee per unit _______________

▪ Please list any additional fees with respective explanations below.

In submitting the above quote, we accept all stated conditions and guarantee full compliance as to analysis, quality, prices, and delivery on any item specified herein as stipulated below.

DATE: ______________________________ SIGNED: ____________________________

COMPANY: _________________________

TITLE: _____________________________

ADDRESS: __________________________

TELEPHONE: ________________________

FAX: ________________________

DUE: May 8, 2026

REFERENCE FORM

REFERENCES TO SIMILAR CUSTOMERS TO WHOM YOU HAVE

PROVIDED SIMILAR SERVICES

(YOU MUST HAVE A MINIMUM OF THREE (3)

#1. Name: ___________________________________________

Title: _______________________Phone:______________

Company: ___________________________________________

City/State: ___________________________________________

#2. Name: ___________________________________________

Title: _______________________Phone:_______________

Company: ___________________________________________

City/State: ___________________________________________

#3. Name: ___________________________________________

Title: _______________________Phone:______________

Company: ___________________________________________

City/State: ___________________________________________

AGREEMENT

AGREEMENT, made this day of , 2026, between the

OWNER: Freetown - Lakeville Regional School Committee and the

CONTRACTOR:

The PROJECT IS: Rubbish Removal / Recycling Services

The Owner and the Contractor agree as set forth below.

ARTICLE 1

THE CONTRACT DOCUMENTS

1.1 The Contract Documents consist of this Agreement and the Quote Request for this project issued by the Owner. These form the Contract, and are as fully a part of the Contract as if attached to this Agreement or repeated herein. The Contract represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations, representations or agreements, either written or oral. If anything in the other Contract Documents is inconsistent with this Agreement, this Agreement shall govern.

ARTICLE 2

THE WORK OF THIS CONTRACT

2.1 The Contractor shall execute the entire Work described in the Contract Documents as follows:

1)Trash disposal, cardboard, and plastic bottle/single-stream recycling service

- Compactors are emptied as needed when the pressure gauge indicates the container is full.

- Cardboard dumpsters and 10 yd Trash dumpster emptied bi-weekly (2x/month)

- Plastic bottle/ paper single-stream bins emptied bi-weekly (2x/month)

- Provide a wood/wood pallet dumpster for recycling purposes. Transport and recycle per Board of Health / DEP requirements.

2) At the contractor’s expense, provide general routine and preventative maintenance and emergency service for contractors’ equipment in use at school facilities.

ARTICLE 3

RELATIONSHIP OF THE PARTIES

3.1 The Contractor accepts the relationship of trust and confidence established by this Agreement and covenants with the Owner to utilize the Contractor’s best skill, efforts and judgment in furthering the interests of the Owner; to furnish efficient business administration and supervision; to make best efforts to furnish at all times an adequate supply of workers and materials; and to perform the Work in the best way and most expeditious and economical manner consistent with the interests of the Owner. The Owner agrees to exercise best efforts to enable the Contractor to perform the Work in the best way and most expeditious manner by furnishing and approving in a timely way information required by the Contractor and making payments to the Contractor in accordance with the requirements of the Contract Documents.

ARTICLE 4

DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION

4.1 The date of commencement of the project is July 1, 2026

4.2 The Contractor shall achieve substantial completion of the entire work no later than

June 30, 2027, in year one. Based upon satisfactory performance in June 2027 in renewal year 1, and June 2028 in renewal year two.

ARTICLE 5

CONTRACT SUM

5.1 The Owner shall pay the Contractor in current funds for the Contractor’s performance of the Contract the Contract sum of :

▪ Annual (1 yr.) service fee 10 yd. TRASH dumpster per unit (landfill fees included)

1 unit total price _______________

▪ Annual (1 yr.) service fee 10 yd. CARDBOARD dumpster per unit (landfill fees included) 5 dumpsters total price _______________

▪ Annual (1 yr.) lease of 35 yd. compactors 5 compactors total price _______________

▪ Compactor container pick-up/ dump fee each per unit price _______________

▪ Price per ton land-fill trash fee (compactor and open top container) _______________

▪ Annual (1 yr.) service fee plastic recycle bin per facility (set of 6 ea.)

5 Sets of 6 bins total price_______________

▪ 30 yd. open-top roll-off container drop/ pick-up/ dump fee per unit _______________

ARTICLE 6

CHANGES IN THE WORK

6.1 Changes in the work may be accomplished after execution of the Contract only by a written Change Order signed by the Freetown-Lakeville Superintendent of Schools.

ARTICLE 7

PROTECTION OF PERSONS AND PROPERTY

7.1 The Contractor shall be responsible for initiating, maintaining, and supervising all safety precautions and programs in connection with the performance of the Contract.

7.2 The Contractor shall provide its safety, spill prevention, and emergency plans for the work to the owner upon commencement of this contract.

7.3 The Contractor shall take responsible precautions for the safety of, and shall provide reasonable protection to prevent damage, injury, or loss to;

1. Employees on the Work and other persons who may be affected thereby;

2. Work, materials, and equipment to be incorporated therein, whether in storage on or off the site, under the care, custody, or control of the Contractor or the Contractor’s Subcontractors or Sub-subcontractors.

3. Other property at the site or adjacent thereto, such as trees, shrubs, lawns, walks, pavement, roadways, structures, and utilities not designated for removal, relocation, or replacement in the course of construction.

7.4 The Contractor shall give notices and comply with applicable laws, ordinances, rules, regulations, and lawful orders of public authorities bearing on the safety of persons or property or their protection from damage, injury, or loss.

7.5 The Contractor shall erect and maintain, as required by existing conditions and performance of the Contract, reasonable safeguards for safety and protection, including posting safety regulations and notifying owners and users of adjacent sites and utilities.

ARTICLE 8

INSURANCE AND BONDS

8.1 The Contractor shall procure and maintain in a company or companies lawfully authorized to do business in the State of Massachusetts such insurance as will protect the Contractor from claims set forth below which may rise out of or result from the Contractor’s operations under the Contract and for which the Contractor may be legally liable, whether such operations be by the Contractor or by a Subcontractor or by anyone directly or indirectly employed by any of them, or by anyone for whose acts any of them may be liable:

1. claims under workers’ compensation, disability benefit, and other similar employee benefit acts which apply to the Work to be performed;

2. claims for damages because of bodily injury, occupational sickness or disease, or death of the Contractor’s employees;

3. claims for damages because of bodily injury, sickness or disease, or death of any person other than the Contractor’s employees;

4. claims for damages insured by usual personal injury liability coverage which are sustained (1) by a person as a result of an offense directly or indirectly related to employment of such person by the Contractor, or (2) by another person;

5. claims for damages, other than to the Work itself, because of injury to or destruction of tangible property, including loss of use resulting therefrom;

6. claims for damages because of bodily injury, death of a person, or property damage arising out of ownership, maintenance, or use of a motor vehicle.

8.2 The insurance required by Paragraph 8.1 shall be written for not less than One

Million Dollars ($1,000,000) in Coverages, whether written or an occurrence or claims-made basis, shall name the owner as an additional insured as its interests may appear, and shall be maintained without interruption from the date of commencement of the work until the date of final payment and termination of any coverage required to be maintained after final payment.

8.1 Certificates of Insurance acceptable to the Owner shall be filed with the Superintendent of Schools before commencement of the Work. These Certificates and the insurance policies required by Paragraph 8.1 shall contain a provision that coverages afforded under the policies will not be canceled or allowed to expire until at least 10 days' prior written notice has been given to the Owner. If any of the foregoing insurance coverages are required to remain in force after final payment and are reasonably available, an additional certificate evidencing continuation of such coverage shall be submitted with the final Application for Payment. Information concerning the reduction of coverage shall be furnished by the Contractor with reasonable promptness in accordance with the Contractor’s information and belief.

8.2 The Contractor shall furnish a Bond covering faithful performance of the Contract and payment of obligations arising thereunder. The amount of the Bond shall be equal to 100 percent of the Contract sum. The Contractor shall deliver the required Bond to the Superintendent of Schools no later than three days following the execution of this Agreement.

ARTICLE 9

INDEMNIFICATION

9.1 To the fullest extent permitted by law, the Contractor shall indemnify and hold harmless the Owner, and its agents and employees, of any claims, damages, losses and expenses, including but not limited to attorneys’ fees, arising out of or resulting from performance of the Work, provided that such claims, damage, loss or expenses are attributable to bodily injury, sickness, disease or death, or to injury to or destruction of tangible property (other than the Work itself) including loss of use resulting therefrom, but only to the extent caused in whole or in part by negligent acts or omissions of the Contractor, a subcontractor, anyone directly or indirectly employed by them or anyone for whose acts they may be liable, regardless of whether or not such claim, damage, loss or expenses are caused in part by a party indemnified hereunder.

ARTICLE 10

PROGRESS PAYMENTS

10.1 Based upon Applications for Payment submitted to the Owner by the Contractor and based on the Certificates of the Superintendent of Schools and Director of Finance that the necessary work has been performed, the Owner shall make progress payments on the account of the Contract Sum to the Contractor as provided below:

Monthly for work completed the prior month.

ARTICLE 11

OWNER’S RIGHT TO STOP THE WORK OR CARRY OUT THE WORK

11.1 If the Contractor fails to correct Work which is not in accordance with the requirements of the Contract Documents or fails to carry out Work in accordance with the Contract Documents, the Owner, by written order signed, may order the Contractor to stop the Work, or any portion thereof, until the cause for such order has been eliminated.

11.2 If the Contractor defaults or neglects to carry out the Work in accordance with the Contract Documents and fails within seven days after receipt of written notice from the Owner to commence and continue correction of such default or neglect with diligence and promptness, the Owner may, after such seven-day period give the Contractor a second written notice to correct such deficiencies within a second seven-day period. If the Contractor, within such seven-day period after receipt of such second notice, fails to commence and continue to correct any deficiencies, the Owner may, without prejudice to other remedies the Owner may have, correct such deficiencies. In such a case, an appropriate Change Order shall be issued deducting from payments then or thereafter due the Contractor the cost of correcting such deficiencies. If payments then or thereafter due the Contractor are not sufficient to cover such amounts, the Contractor shall promptly pay the difference to the Owner.

ARTICLE 12

LABOR AND MATERIALS

12.1 Unless otherwise provided in the Contract Documents, the Contractor shall provide and pay for labor, materials, equipment, tools, construction equipment and machinery, water, heat, utilities, transportation, and other facilities and services necessary for proper execution and completion of the Work, whether temporary or permanent, and whether or not incorporated or to be incorporated into the Work.

12.2 The Contractor shall at all times follow policies and practices reasonably designed to avoid work stoppage or strikes and shall enforce strict discipline and good order among the Architect’s employees and other persons carrying out the Contract. The Contractor shall not permit the employment of an unfit person or persons not skilled in tasks assigned to them.

ARTICLE 13

WARRANTY

13.1 The Contractor warrants to the Owner that materials and equipment furnished under the Contract will be of good quality and new unless otherwise required or permitted by the Contract Documents, that the Work will be free from defects not inherent in the quality required or permitted, and that the Work will conform with the requirements of the Contract Documents. Work not conforming to the requirements, including substitutes not properly approved and authorized, may be considered defective. The Contractor’s warranty excludes remedies for damage or defect caused by modifications not executed by the Contractor, improper or insufficient maintenance, improper operation, or normal wear and tear under normal usage. If required by the Superintendent of Schools, the Contractor shall furnish satisfactory evidence as to the kind and quality of materials and equipment.

ARTICLE 14

PERMITS, FEES, AND NOTICES

14.1 Unless otherwise provided in the Contract Documents, the Contractor shall secure and pay for the building permit and other permits and governmental fees, licenses, and inspections necessary for proper execution and completion of the Work, which are customarily secured after execution of the Contract, and are legally required when bids are received or negotiations conducted.

ARTICLE 15

FORCE MAJUERE

15.1 The School District and the Contractor shall not be liable for the failure to perform it’s duties under the terms of this contract if such failure is caused by catastrophe, riot, war, strike, governmental order or regulation, fire, accident, epidemic, pandemic, or similar public health emergency, act of God, or similar or different contingency beyond the control of either party. In the case of a “force majeure event”, the Contractor and the School District shall cooperate in good faith in determining how best to provide the rubbish removal and recycling services contemplated hereunder the circumstances.

ARTICLE 15

MISCELLANEOUS PROVISIONS

16.1 GOVERNING LAW

The Contract Documents shall be governed and construed in accordance with the laws of the State of Massachusetts.

16.2 SUCCESSORS AND ASSIGNS

The Owner and Contractor respectively bid themselves, their partners, successors, assigns, and legal representatives to the other party hereto and to partners, successors, assigns, and legal representatives of such other party in respect to covenants, agreements, and obligations contained in the Contract Documents. Neither party to the Contract shall assign the Contract as a whole without the written consent of the other. If either party attempts to make such an assignment without such consent, the party shall nevertheless remain legally responsible for all obligations under the Contract.

16.3 WRITTEN NOTICE

Written notice shall be deemed to have been duly served if delivered to or sent by registered or certified mail to the following addresses:

OWNER: Freetown Lakeville Regional School Committee c/o John Higgins SBO/MCPPO

Director of Finance and Operations

CONTRACTOR:

16.4 RIGHTS AND REMEDIES

Any dispute arising under the Contract Documents shall be resolved by a Court of competent jurisdiction located in the State of Massachusetts and not through arbitration.

This agreement is entered into as of the day and year first written above and is executed in at least two original copies, of which one is to be delivered to the Contractor and one to the Owner.

OWNER: Freetown Lakeville Regional School Committee

(Signature) John Higgins SBO/MCPPO, Director of Finance and Operations Freetown-Lakeville Regional School District

CONTRACTOR:

(Signature)

(Print name and title)