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REQUEST FOR PROPOSALS Title of Consulting Services: Licensing Model - Bridging the Gap to Commercial Application of Innovation Licensing Framework and Valuation Model

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Page 1: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

REQUEST FOR PROPOSALS

Title of Consulting Services:

Licensing Model - Bridging the Gap to Commercial Application of Innovation

Licensing Framework and Valuation Model

Page 2: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

Letter of Invitation

Request for Proposals: Licensing Model - Bridging the Gap to Commercial Application

of Innovation

The Caribbean Industrial Research Institute (CARIRI) wishes to contract the services of a

Consultant to develop a model for the licensing or sale of products or services developed

within the framework of its Idea Advisory Service (IAS); which is currently the focus of a

collaborative project involving CARIRI and the Inter-American Development Bank (IDB

LAB) titled “Bridging the Gap to Commercial Application of Innovation”. Under this project,

the IAS is being developed and strengthened with financial support from IDB LAB.

In this regard, CARIRI hereby requests proposals for the provision of services for the

consulting assignment: Development of a Model for the Licensing or Sale of

Products/Services.

Details on the services required are provided in the Terms of Reference (Appendix I).

A Consultant will be selected under the Quality Cost Based Selection (QCBS) method, in

accordance with the policies of the IDB LAB detailed in the Policies for the Selection and

Contracting of Consultants financed by the Inter-American Development Bank (GN-2350-

15) which can be found at the following website: http://www.iadb.org/procurement.

This Request for Proposals (RFP) includes the following documents:

• Letter of Invitation

• Instructions to Consultants

• Appendix I - Terms of Reference

• Appendix II - Evaluation Criteria

• Appendix III - Vendor Registration Form

Page 3: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

INSTRUCTIONS TO CONSULTANTS

GENERAL INFORMATION

Submission Requirements

The Consultant must provide the following:

1. One (1) original Technical Proposal marked “original”. The Technical proposal should

outline how the Consultant will achieve the objectives of the consultancy and perform

the activities outlined in the Terms of Reference (Appendix I).

2. One (1) separate original Cost Proposal detailing the Consultant’s fee and the inputs to

those costs marked “original”.

3. One (1) completed Vendor Registration Form (Appendix III).

The original Technical Proposal together with the Vendor Registration Form (Appendix III)

should be placed in a sealed envelope clearly marked “TECHNICAL PROPOSAL”.

Similarly, the original Price Proposal should be placed in a sealed envelope clearly marked

“PRICE PROPOSAL” followed by the name of the consulting assignment, and with a

warning “DO NOT OPEN WITH THE TECHNICAL PROPOSAL”.

The envelopes containing the Technical Proposal, Vendor Registration Form (Appendix III)

and Price Proposal should be placed into an outer envelope and sealed. This outer envelope

should bear the submission address and consultancy title. Proposals must be submitted no

later than 4:00pm, April 9th, 2020 and should be addressed to:

Chairman

Tenders Committee

Caribbean Industrial Research Institute (CARIRI)

UWI Campus

ST AUGUSTINE.

Failure to keep the Price Proposal separate from the Technical Proposals will disqualify

the bid.

Tender Validity Period: Proposals must remain valid up to 60 days after the submission date,

i.e. until: June 8th, 2020.

Queries: Consultants may request clarification of the RFP no later than 5 days before the

submission date. Any request for clarification must be sent in writing, or by standard

electronic means to:

Mr Reyad Ali

Procurement Officer

CARIRI

Page 4: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

UWI Campus

St Augustine

Tel: 1-(868)-299-0210 ext. 5061

Fax: 1-(868)-662-7177

Email: [email protected]

Expected Commencement Date

The expected date for commencement of consulting services is May 11th, 2020.

PREPARATION OF PROPOSALS

Technical Proposal

Consultants are required to submit a Full Technical Proposal written in English. The

Technical Proposal should provide the following information:

• A brief description of the Consultant’s organization and an outline of recent

experience of the Consultant.

• Comments and suggestions on the Terms of Reference including workable suggestions

that could improve the quality/effectiveness of the assignment.

• A description of the approach, methodology and work plan for performing the

assignment. The technical approach and methodology, work plan, and organization

and staffing should be addressed as follows:

a) Technical Approach and Methodology. Explain your understanding of the

objectives of the assignment, approach to the services, methodology for

carrying out the activities and obtaining the expected output.

b) Work Plan. Propose the main activities of the assignment, their content and

duration, phasing and interrelations, milestones (including interim approvals by

CARIRI), and dates for delivery. The proposed work plan should be consistent

with the technical approach and methodology, showing understanding of the

TOR and ability to translate them into a feasible working plan. A list of the

final deliverables, including documents, reports and tables to be delivered as

final output, should be included here.

c) Organization and Staffing. Propose the structure and composition of your team.

List the main disciplines of the assignment, the key expert responsible, and

proposed technical and support staff.

Page 5: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

• CVs of the Professional staff signed by the staff themselves or by the authorized

representative of the Professional Staff.

• Two (2) references for similar consultancies provided within the past ten (10) years.

Price Proposal

The Price Proposal should list all costs associated with the assignment, including (a)

remuneration for staff and (b) expenses. Consultants should express the price of their services

in Trinidad & Tobago Dollars (TT$).

EVAUATION OF PROPOSALS

A Consultant will be selected under the Quality Cost Based Selection (QCBS) process, in

accordance with the policies of the IDB LAB as detailed in the Policies for the Selection and

Contracting of Consultants financed by the Inter-American Development Bank (GN-2350-4)

(http://www.iadb.org/procurement).

Technical Proposals will be evaluated on the basis of their responsiveness to the Terms of

Reference (TOR), applying the evaluation criteria, sub-criteria, and point system specified in

the Evaluation Criteria (Appendix II). Each responsive Proposal will be given a technical

score. A Technical Proposal will be rejected if it fails to achieve the minimum technical

score indicated in the Evaluation Criteria and in such a case, the Price Proposal will be

returned to the Consultant unopened.

After the technical evaluation is completed, CARIRI will notify Consultants that have

secured the minimum qualifying mark or higher, of the date, time and location for opening

the Price Proposals. Consultants’ attendance at the opening of Price Proposals is optional.

Proposals that exceed the indicated budget shall be rejected. The Consultant that has

submitted the highest ranked technical proposal shall be selected and invited to negotiate a

contract with CARIRI.

Page 6: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

ELIGILIBITY

Shortlisted Consultants may associate with other shortlisted Consultants.

If a shortlisted Consultant intends to associate with Consultants who have not been shortlisted

and/or individual expert(s), these other Consultants and/or individual expert(s) must be from

the following member countries of the IDB LAB:

Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Canada, Chile, China, Colombia,

Costa Rica, Dominican Republic, Ecuador, El Salvador, France, Guatemala, Guyana, Haiti,

Honduras, Italy, Jamaica, Japan, Korea, Mexico, Netherlands, Nicaragua, Panama, Paraguay,

Peru, Portugal, Spain, Suriname, Sweden, Switzerland, United Kingdom, United States,

Uruguay and Venezuela.

Page 7: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

APPENDIX I - Terms of Reference

for

Development of a Model for the Licensing/Sale of Products or Services

“BRIDGING THE GAP TO COMMERCIAL APPLICATION OF INNOVATION”

ATM/ME-16607-TT

The Caribbean Industrial Research Institute (CARIRI) is Trinidad and Tobago’s primary

agency with responsibility for developing the country’s technological base. The

organization is widely recognized as a trusted provider of value added

technical/technological services and business solutions to industries and firms in the

region. Originally established to deliver technical, quality and metrology services to

private firms, CARIRI has evolved over the years into a provider of a wide range of

services, encompassing analytical and engineering, as well as associated

consultancy; training; and innovation facilitation and entrepreneurship

development. The latter is provided via the Institute’s Centre for Enterprise

Development (CED) which was established to facilitate research, development and

innovation capacity building in Trinidad and Tobago.

CARIRI is seeking to contract an experienced and capable Consultant to develop a

model for the licensing and/or sale of products or services developed under its Idea

Advisory Services (IAS) Programme.

1.0 Background

It is widely accepted that innovation and business sophistication are key

drivers of diversification and competitiveness in any economy. However, the

creation of an innovation, knowledge-driven economy demands that critical

gaps in the innovation eco-system, which constitute hindrances to the

achievement of the desired developmental outcomes, be addressed. These

constraints are reflected at a macro level in Trinidad and Tobago’s ranking of

87 out of 141 countries under Pillar 12: Innovation Capability, in the World

Economic Forum (WEF) 2019 Report, despite the country’s categorization as

an innovation driven economy.

Page 8: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

Among the identified pertinent shortcomings in Trinidad and Tobago are the

following: (1) Inadequate level of knowledge and experience in the area of

Technology Transfer/Commercialization; (2) Bias of existing support systems

towards firm creation reflecting a tendency to equate innovation with

entrepreneurship; (3) Limited awareness of the importance and general

underutilization, of Intellectual Property Rights (IPR) as a tool in the economic

development process; and (4) Underdevelopment of capital markets, in

particular, avenues for financing research and development and business

start-ups.

These gaps have also been identified as factors contributing to low levels of

investment by SMEs in Trinidad and Tobago relative to the region. In addition,

a recent (2016) IDB LAB study characterizes a significant segment of

established firms in the private sector of Trinidad and Tobago, as mature

and/or declining. These entities require innovations to reinvent themselves,

but the human, financial and technical resources, and the innate capacity to

innovate, may be lacking in enterprises in the late stage life cycle. To stay

competitive, one option is to leverage technology transfer from universities

and other inventors, via outright acquisition or licencing of innovations for

commercialization. Another is to accelerate innovation processes with

dedicated technical support, but Trinidad and Tobago currently lacks

programs and institutions that can facilitate such investment.

Given the foregoing, CARIRI, with the assistance of the IDB LAB, has

embarked on a 3-year project which aims to address the relative lack of

innovation demonstrated by individuals and firms in Trinidad and Tobago.

The objective of the Project is to build capacity for Innovation on a national

scale by facilitating both individuals and enterprises in progressing

creative/innovative ideas, inventions and projects to implementation. The

Project aims to harness and transform the creativity that is rampant in the

country into commercial endeavour that is capable of widespread

employment creation and income generation, as well as foreign exchange

earnings.

The Project is centered around CARIR’s IAS which is adapted from the Danish

Technological Institute’s (DTI’s) Inventor Advisory Service (IAS) and is intended

Page 9: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

to facilitate screening and development of innovative ideas to the

commercialization stage, via either start up or licensing.

The Project has three (3) main components, viz:

1. Awareness Raising and Stakeholder Outreach; which is expected to

increase the pipeline of individual, dynamic microenterprise and SME

applicants to the IAS Programme and to sensitize larger firms on the

model for acquisition of innovations;

2. Adaptation and Delivery of the IAS Programme; which entail the full

adaptation of the DTI model to the local business environment and

context, and implementation of all of the elements of the Programme,

from ideation to commercialization.

3. Scaling of the IAS Model; the objective of which is to support horizontal

scaling of the IAS Model by building CARIRI’s capacity to sustain and

scale programme delivery and to promote the replication of the IAS

Programme in other jurisdictions in the Caribbean region.

CARIRI is now engaged in the execution of both the first and second

components of the project, having already conducted several stakeholder

outreach and awareness building sessions, as well as ideation sessions

resulting in the registration of several individuals and SMEs in the Project.

2.0 Objectives

The objective of the consultancy is to develop a model for the licensing or

sale of products or services created under the IAS Programme. It also includes

the training of IAS staff in the implementation of the model.

Specifically, the Consultant will design and develop a methodology for the

procurement and negotiation of agreements between participants of the IAS

Programme who have developed products or services under the Programme

and individuals or companies interested in the licensing of these

products/services. A significant aspect of this methodology will be the

development of a process for the valuation of patents for goods/services.

Additionally, the Consultant will work with members of the Project Team to

Page 10: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

develop contract templates for the licensing of goods and services

developed under the IAS Programme. Such contract templates must include

scope of the agreement, contract terms, limits and restrictions, financial

arrangements and rights of parties including intellectual property rights.

Finally, given the importance of the transfer of the approach and requisite

know-how to CARIRI’s IAS Team in building capacity within the unit, in

addition to training on the model, the Consultant will lead the IAS Team in the

execution of one (1) licensing agreement for a product/service developed

under the Programme.

3.0 Scope of Works

The Scope of Works for the consultancy encompasses the following:

▪ Development of a methodology for the procurement and negotiation

of agreements between IAS Programme participants and potential

licensees, for products/services developed within the Programme. The

methodology will include the process for the determination of the

value of the IP, if applicable, of the product or service in question and

will also detail the process to be followed for securing a potential

licensee and negotiation of a license agreement. The agreement will

include, but should not be confined to, the following:

1. Scope of the agreement including exclusivity, territorial rights

and guarantees of sales;

2. Financial Arrangements governing the deal;

3. Timeframe of the agreement along with options for renewal or

modification;

4. Quality control, assurance and protection including

specification regarding the quality of products produced under

the agreement as well as performance standard in terms of

level of investment in product or technology;

5. Scaling terms dependent on level of manufacture/use of

product;

6. Insurance and indemnification against claims or liabilities; and

7. Accounting, reports and audit requirements.

Page 11: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

▪ Development of Licensing Agreement Templates to cover the various

categories of products and services developed under the IAS

Programme. Each template must contain all the elements necessary

for ensuring a comprehensive and robust licensing contract.

▪ The Consultant will be required to develop a training programme for

the IAS Project Team in the execution of the methodology for securing

a potential licensee and negotiation of a license agreement.

Subsequent to internal training and based on the availability of a

suitable candidate, the Consultant will be required to lead the team

through the actual execution of the Licensing Agreement

Methodology, with the result being the conclusion of a licensing

agreement for one (1) participant from within the IAS Programme.

4.0 Deliverables

The deliverables of the consultancy are as follows:

1. A Licensing Agreement Procurement and Negotiation Methodology;

2. Licensing Templates for the major categories of products and/or

services developed under the IAS Programme;

3. Development and execution of a Training Programme for the IAS Team

on the Licensing Agreement Procurement and Negotiation

Methodology; and

4. Facilitation of the conclusion of one (1) License Agreement,

depending on the availability of a suitable candidate.

5.0 Reporting Requirements

The Consultant will work in close collaboration with the Project Co-ordinator

and the Project Chief. The Consultant will report to the Project Chief.

The Consultant will submit the draft and final deliverables to CARIRI on dates

to be agreed between the two parties at the inception meeting and will be

Page 12: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

required to address any pertinent comments/feedback prior to submission of

the final outputs.

6.0 Selection Process

The Consultant will be selected in accordance with the procedures set out in

the IDB LAB’s Policies for the Selection and Contracting of Consultants

financed by the IDB Lab.

7.0 Qualifications and Experience

The Consultant must:

• Possess relevant technical qualifications and have at least 10 years

relevant experience in the provision of similar services;

• Have demonstrated experience in the development of business

models in similar environments including tried and tested

methodologies for the undertaking of the assignment;

• Be able to work as part of a Team; and

• Have effective presentation, writing and communication skills.

8.0 Duration of Assignment

The Consultant will be contracted for a period not exceeding thirty (30)

contact days, commencing after signing of the Contract.

Page 13: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

APPENDIX II - EVALUATION CRITERIA

Technical Proposals will be evaluated on the following criteria:-

Criteria Max Score

(i) Specific experience of the Lead Consultant relevant to the assignment:

a. Technology Transfer Modalities, with particular focus on Technology

Brokerage, Valuation, Licensing and IPR

b. Working with Inventors, Entrepreneurs and SMEs

Total Points for criterion (i)

30

15

45

(ii) Adequacy of the proposed methodology and work plan in responding to the

Terms of Reference:

a) Technical approach and methodology

b) Work Plan

Total Points for criterion (ii)

15

15

30

(iii) Key professional staff qualifications and competence for

the assignment:

a) Team Leader General Qualifications

b) Relevance of technical experience for the assignment

c) Experience working with Inventors, Entrepreneurs and SMEs

Other Consultants

d) General Qualifications

e) Relevance of technical experience for the assignment

f) Experience working with Inventors, Entrepreneurs and SMEs

Total Points for criterion (iii)

5

5

5

3

5

2

25

TOTAL Points for the three criteria: 100

The minimum technical score required to pass is: 70 Points

Page 14: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

APPENDIX III – VENDOR REGISTRATION FORM

Page 15: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

VENDOR REGISTRATION FORM DOCUMENT#

PROC.F.04

Issue/ Rev#:1/01 Issue Date: May 4th

2018 Page 1 of 5

CARIRI reserves the right to request a Second Party (Supplier/Vendor) Audit of your facilities.

(Please read the attached document before completing this form – Forward completed form to

Procurement Department.)

SECTION A- General Information

1. Business Name : _________________________________________________________________

2. Business Address: ___________________________________________________________________

3. Mailing Address: ___________________________________________________________________

4. Telephone Number(s): _____________________ Facsimile Number: _____________________

5. Type of Business:

Sole Trader Partnership Limited Liability Company Commission Agent

Other: (Specify) ______________________________________________________

6. Age of Business: _____________ year(s)

7. Is your business part of or associated with a group of companies? Yes No

If Yes, state: _____________________________________________________________________

8. Manpower Size and Composition of Company

1 -10 11 – 30 31 – 70 70 – 100 100 & Over

9. Are you registered for VAT in Trinidad & Tobago? Yes No

10. Please provide valid copies of the following documents, where applicable:

Articles of Incorporation

Certificate of Incorporation

Notice of Directors

Notice of Address

Notice of Secretary

Annual Return of Directors

VAT Registration Certificate

Tax Clearance Certificate

VAT Clearance Certificate

National Insurance Compliance Certificate

Tunapuna Post Office Trinidad and Tobago Telephone: (868) 299-0210 Telefax: (868) 662-7177 E-mail: [email protected]

Page 16: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

VENDOR REGISTRATION FORM DOCUMENT#

PROC.F.04

Issue/ Rev#:1/01 Issue Date: May 4th

2018 Page 2 of 5

11. Has your company provided goods or services to CARIRI in the past? Yes No

If yes, give brief description of goods provided.

________________________________________________________________________________

________________________________________________________________________________

12. Does your company have a Quality Management System in place? Yes No

If yes, please specify the Standard to which it conforms ___________________________________

If certified, please attach a copy of the latest certificate as appropriate.

13. List of major Clients and Equipment supplied.

__________________________________________________________________________________

__________________________________________________________________________________

Attach additional information as appropriate.

14. Please provide two Client references (within the last 2 years):_____________________________________

__________________________________________________________________________________

15. Does your company have any court matters, notices or fines arising from health, safety or environmental

matters? Yes No

If yes, please attach a brief summary of matters arising for the past 2 years.

16. Authorised Signatures on Contracts:

Name (block letters) Sample Signatures

___________________________ ___________________________________

___________________________ ___________________________________

___________________________ ___________________________________

Please provide any other relevant information:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Page 17: REQUEST FOR PROPOSALS · constraints are reflected at a macro level in Trinidad and Tobago’s ranking of 87 out of 141 countries under Pillar 12: Innovation Capability, in the World

VENDOR REGISTRATION FORM DOCUMENT#

PROC.F.04

Issue/ Rev#:1/01 Issue Date: May 1st, 2018 Page 3 of 5

SECTION B- HSE Requirements

Instructions:

Contractors with less than 26 employees are required to complete Part 1.

Contractors with 26 or more employees or more are required to complete Part 2.

If your organisation is certified to the STOW Program, you are exempted from completing this Section. Please submit a

copy of the valid certificate.

Part 1: For Vendors with less than 26 employees

1 Do the employees in your company have any HSE

Training?

Yes No

If yes, give a summary of the HSE Training Received

2 Has your company had any work related incidents?

(If yes, attach a summary of your company’s incidents

for the last year)

Yes No

3 Do any of your employees have any previous or persisting health issues that may affect work conducted for

or on behalf of CARIRI? If yes, please state who and what these health issues are.

4 Do your workers/ company have the required

certifications and/or license in the relevant fields?

If “Yes” attach a copy of the relevant certificates and /

or licences.

Yes No

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VENDOR REGISTRATION FORM DOCUMENT#

PROC.F.04

Issue/ Rev#:1/01 Issue Date: May 1st, 2018 Page 4 of 5

Part 2: For Vendors with 26 or more employees.

1 Does your company have an HSE Policy Statement?

If yes please attach a copy.

Yes No

2 Is there a person in your company that is responsible

for HSE Management functions?

Yes No

Please state the name and details for this person:

Name: _________________________________________________________

Position in Company: _________________________________________________________

Contact Number: _________________________________________________________

Email Address: ________________________________________________________

3 Does your organisation have a new hire orientation

program?

Yes No

If yes, provide a summary of the information/topics covered in this program.

4 Is there a system in place for developing Safe Systems

of Work? (E.g. JSA, Toolbox, Risk Assessments etc.)

If yes, please provide a sample.

Yes No

5 Do your workers/ company have the required

certifications and/or license in the relevant fields?

If “Yes” attach a copy of the relevant certificates and /

or licences.

Yes No

6 Does the company have a written procedure for

reporting Incidents and Accidents? If yes, Please

attach a copy of procedure.

Yes No

7 Has your company had any work related incidents?

(If yes, attach a summary of your company’s incidents

for the last year)

Yes No

8 How often are your equipment and vehicles checked to ensure proper and safe working conditions are

maintained?

9 Does your Company conduct Safety Inspections? If

yes, who conducts these inspections?

Please attach a sample copy of inspection checklist?

Yes No

10 How often are these Safety Inspections conducted? Weekly Monthly

Quaterly Once per Project

Other

11 Do you have a Substance Abuse Policy/Program in

place? If yes, please attach a copy.

Yes No

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VENDOR REGISTRATION FORM DOCUMENT#

PROC.F.04

Issue/ Rev#:1/01 Issue Date: May 1st, 2018 Page 5 of 5

Declaration: I hereby confirm that the information provided in this Vendor Registration Form is true and correct.

NAME _____________________________

(BLOCK LETTERS)

SIGNATURE: _____________________________

DESIGNATION: ______________________________

COMPANY STAMP: _____________________________

DATE: _____________________________