REQUEST FOR PROPOSAL (RFP)

FOR

UNARMED SECURITY GUARD SERVICES

RFP #: 2021 CE-01

Release Date: 11/12/2021

RFP Due Date: 12/03/2021 no later than 3:00 P.M EST

KALAMAZOO PUBLIC LIBRARY

ATTN: KEVIN KING

HEAD OF COMMUNITY ENGAGEMENT

315 S ROSE ST

KALAMAZOO, MI 49007

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Table of Contents

Table of Contents Table of Contents ...................................................................................................................................... 2

1. Introduction ...................................................................................................................................... 3

2. Project Overview ............................................................................................................................... 4

3. Qualifications and Requirements...................................................................................................... 5

4. Evaluation and Selection Process ..................................................................................................... 5

5. Instructions to Respondents ............................................................................................................. 6

6. Scope of Service ................................................................................................................................ 8

7. Billing and Invoicing ........................................................................................................................ 12

Appendix A: Pricing Schedule ................................................................................................................. 13

Appendix B: Non-Collusion Affidavit ....................................................................................................... 14

Appendix C: References .......................................................................................................................... 15

Appendix D: Rules of Conduct for Library Use ........................................................................................ 16

Appendix E: Signature Page .................................................................................................................... 18

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1. Introduction

A. GENERAL INFORMATION 1. Purpose

The purpose of this Request for Proposal (RFP) is to provide unarmed security guard services at the Kalamazoo Public Library.

2. Locations:

• Kalamazoo Public Library Central Branch is located at: 315 S Rose St Kalamazoo, MI 49007.

• Kalamazoo Public Library Alma Powell Branch is located at: 1000 W Paterson St Kalamazoo, MI 49007.

• Kalamazoo Public Library Eastwood Branch is located at: 1112 Gayle Ave Kalamazoo, MI 49048.

• Kalamazoo Public Library Oshtemo Branch is located at: 7625 W Main St Kalamazoo, MI 49009.

• Kalamazoo Public Library Washington Square Branch is located at: 1244 Portage St Kalamazoo, MI 49001.

• Kalamazoo Public Library Mobile Library. 3. Days of Operation

The successful bidder shall be required to provide unarmed security guard services seven (7) days a week or during the working hours of the Library.

B. CALENDAR OF EVENTS

RFP Release Date

November 12, 2021

Pre-Bid Conference NA

Deadline to submit written questions November 19, 2021, no later than 3:00 P.M. EST

Proposal Due Date

December 3, 2021, no later than 3:00 P.M EST

Online Vendor Presentation Date

TBD

C. QUESTIONS

All questions regarding the proposal will be accepted via email only. The deadline for submitting questions for this RFP is on or before November 19, 2021, no later than 3:00 P.M. EST.

D. CONTACT WITH LIBRARY PERSONNEL All contact regarding this RFP, or any matter relating thereto, must be in writing and shall be via email attention; Kevin King RFP@kpl.gov.

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E. PRE-BID CONFERENCE

This bid is not subject to pre-bid conference.

2. Project Overview

A. STATEMENT OF PURPOSE The Kalamazoo Public Library (hereafter referred to as “The Library”) is soliciting bids from qualified firms to provide Unarmed Security Guard Services (hereafter referred to as “Contract”). The purpose of the Contract is to provide unarmed security services to the Kalamazoo Public Library as further described in this Request for Proposal under Section 6: Scope of Service. However, the Library recognizes that there may be arrangements different from those requested in the RFP that would afford additional benefits to the Library while satisfying the applicable requirements of this RFP. Accordingly, you may submit alternative proposals for consideration, which offer additional benefits in addition to the requested baseline proposal. These alternatives will be evaluated in conjunction with the primary (baseline) approach for each proposal.

B. BACKGROUND The Kalamazoo Public Library consists of a main location, four branches and a Mobile Library. It is a very well-used Library that is open to the public seven (7) days each week for a total of 222 open hours per week systemwide. The Library had a total of approximately 556,000 visits across all location in 2018 and 540,000 visits per year across all locations in 2019. The Library has 159 employees as of the date of this RFP. Library patrons come from a broad cross section of community members. Typical Library users include students and families, as well as who are unhoused, groups of unsupervised youth and patrons exhibiting behaviors consistent with mental illness and/or substance abuse. In situations where illegal behavior on the part of a patron might be occurring or when staff have difficulty enforcing the Rules of Conduct for Library Use Policy, they call upon assistance from unarmed security guards and/or the police. Systemwide, the Library staff and security manage and respond to approximately 1,300 incidents annually. The vast majority of incidents occur at the Central location. The Library is seeking to retain an experienced and competent firm in providing Unarmed Security Guard Services. Interested and qualified parties who have demonstrated their ability to provide service of legal process are invited to submit proposals, provided they meet the minimum requirement. See Requirements and Qualifications under section VI in this Request for Proposal (RFP).

C. AGREEMENT TERM

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The term of the Agreement shall be for a period of one (1) year, unless sooner terminated or extended as provided in the Agreement. The Library shall have the option to extend two periods of one-year option for a total maximum term not to exceed four (4) years. Each extension option shall be exercised at the sole discretion of the Library.

3. Qualifications and Requirements

Interested and qualified Proposers that can demonstrate their ability to successfully provide the required services outlined in Section 6, Scope of Work, are invited to submit proposal(s), provided they meet the Minimum Mandatory Qualifications and Requirements set forth in Section 6, Scope of Work. Failure of a Proposer to meet all the Minimum Mandatory Qualifications and Requirements may result in the elimination of the proposal from further consideration of this contract. To be determined responsive, proposers must be licensed, fully insured, and bonded as required by the State of Michigan.

4. Evaluation and Selection Process A. SELECTION PROCESS

1. the Library reserves the sole right to judge the contents and presentation of the proposals submitted in response to this RFP and to review, evaluate, and select the successful proposal(s), if any. Evaluations will be based upon the information provided in the proposals and such other information, as the Library deems appropriate.

2. the Library will evaluate all properly and timely submitted proposals. Evaluation of the proposals will be made by the Safety and Security Committee. The Safety and Security Committee will evaluate the proposals and will use the evaluation approach described herein to select a prospective Contractor(s).

3. All proposals will be evaluated based on the criteria listed below. After prospective Contractor(s) have been selected, the Library and the prospective Contractor(s) will negotiate Agreements. If a satisfactory Agreement cannot be negotiated, the Library may, at its sole discretion, begin Agreement negotiations with the next qualified Proposer(s) who submitted a proposal, as determined by the Library.

B. SELECTION CRITERIA The proposal shall enable the Library to evaluate the responsiveness and quality of the proposal to each of the RFP requirements. The evaluation of proposals will be performed by the Safety and Security Committee. If an award is made, it will be made to the responsive and responsible Bidder that offers the Library the greatest value based on an analysis involving a number of criteria including but not limited to:

• Proposer qualification

• Proposer complies with State Guard requirements

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• Proposer understanding and approach of project

• Proposer past experience for similar projects

• Customer References

• Cost

• Proposer has a Diversity, Equity and Inclusion Policy

• Preference will be given to local vendors

C. PROPOSAL DISQUALIFICATION A proposal may be disqualified from consideration because the Library determines it was non-responsive at any time during the evaluation process.

D. PROTEST PROCEDURES In the event a dispute arises concerning the proposal process prior to the award of the contract, the party wishing resolution of the dispute shall submit a request in writing to the Head of Community Engagement in care of:

Kevin King, Head of Community Engagement Kalamazoo Public Library

315 S Rose St Kalamazoo, MI 49007

5. Instructions to Respondents A. PROPOSAL SUBMISSION

• Response to this RFP MUST be submitted electronically via email – NO EXCEPTION –to RFP@kpl.gov

• Late submittals WILL NOT be accepted – NO EXCEPTION • Fax submittals WILL NOT be accepted – NO EXCEPTION

B. FORMAT

Respondents shall submit proposals which are concise, and which specifically respond to the specifications posted in this RFP. Each proposal shall be submitted with a cover letter signed by an authorized person and the following documents:

• Cover Letter – signed by an authorized person

• Executive Summary

• A proposal describing specific capabilities, approaches and proposed methodologies and demonstrate a clear understanding of the nature of the work to be performed described in Section 6 under Scope of Work.

• Resume and certification of key personnel

• Certificate of Insurance with Endorsement letter

• Federal and/or State business licenses

• Diversity, Equity and Inclusion Policy

• Price Proposal

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• References

• Anti-Collusion Statement

• Signature Page

C. CUSTOMER REFERENCE Respondents shall provide a minimum of three (3) letters of references. Each letter must include the name of the firm, description of services provided, date(s) of services and contract amount for projects similar to the services requested in this RFP. See Appendix C.

D. LICENSES AND PERMITS Respondents shall possess all licenses, registrations and permits required by the State of Michigan and the City of Kalamazoo. Such licenses and permits are to be submitted to the Library with the proposal.

E. PROPOSAL EXPENSE Respondents shall be fully responsible for all costs incurred in the development and submission of this RFP.

F. RESPONDENT RESPONSIBILITY The bidder assumes sole responsibility for the complete effort required in submitting a bid proposal in response to this RFP. No special consideration will be given after bid proposals are opened because of a proposer’s failure to be knowledgeable as to all of the requirements of this RFP.

G. INTERPRETATION Should any discrepancies, omissions, or doubt as to their meaning be found in the RFP specifications or requirements, the Respondent shall notify the Library in writing via email. The Library will send written instructions or addenda to all participants in the RFP process. The Library shall not be responsible for oral interpretations.

H. RESERVATIONS The Library reserves the right to do the following at any time and for its own convenience, at its sole discretion:

• To reject any and all proposals without indicating any reasons for such rejection

• Terminate this RFP and issue a new Request for Proposals anytime thereafter

• Extend any or all deadlines specified in the RFP, including deadlines for accepting proposals by issuing an Addendum at any time prior to the deadline for receipt of responses to the RFP

• Procure any services specified in the RFP by other means

• Disqualify any Respondent on the basis of any real or perceived conflict of interest or evidence of collusion that is disclosed by the proposal or other data available to the Library Such disqualification is at the sole discretion of the Library.

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• Reject the proposal of any Respondent that is in breach of or in default under any other agreement with the Library

• Reject any Respondent deemed by the Library to be non-responsive, unreliable, unqualified, or non-responsible

I. TRUTH AND ACCURACY OF REPRESENTATION

False, misleading, incomplete, or deceptively unresponsive statements in connection with a proposal shall be sufficient cause for rejection of the proposal.

J. SUB-CONTRACT AND ASSIGNMENT The Contract binds the heirs, successors, assigns and representatives of Contractor. Prior written consent of the Library, subject to any required state or federal approval, is required before the Contractor may enter into subcontracts for any work contemplated under the Contract, or before the Contractor may assign the Contract or monies due or to become due, by operation of law or otherwise.

K. ADDENDA No one is authorized to amend any of these documents in any respect by an oral statement or to make any representation or interpretation in conflict with their provisions. Any changes to these documents will be issued in writing via Addenda to all participants in the RFP process.

6. Scope of Service A. MINIMUM QUALIFICATIONS

1. Contractor must have an established record of providing professional, commercial

security guard service for a minimum of five (5) years. The Contractor shall provide proof of licensing as a security guard agency per State of Michigan.

2. The Contractor’s security guards providing service at Kalamazoo Public Library must meet the requirements and demonstrate knowledge and ability to perform the tasks as provided in the scope of work.

3. Contractor and any subcontractors must not be under suspension or debarment by any state or federal government agency.

The Contractor must state specifically in the proposal how they meet the minimum qualifications specified above.

B. GENERAL REQUIREMENTS

Note that any assigned security guard/supervisor/liaison that does not meet all legal requirements and all requirements as specified herein, must be removed from post assignment, and must be immediately replaced with a security guard that meets all legal and all specified requirements herein, no exceptions.

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The Contractor will ensure that all assigned security guards meet all the following requirements:

• Abide by all applicable State of Michigan requirements

• Have valid MI driver’s license

• Wear the appropriate uniform at all times while performing duties

• Are very punctual

• Are well-groomed and display a well-maintained appearance

• Perform all the Post Order requirements

• Remain awake and alert at all time

• Are, at all times, professional and courteous in behavior and attitude

• Have a competent command of the English language and efficient in communicating with the public

The Contractor will ensure that a security guard supervisor/liaison meets all the following requirements in addition to the previous requirements:

• Has training and supervisory experience commensurate with the requirements as specified herein

• Ensures that all posts have an approved security guard at their assigned post at the time and for the duration required

• Ensures that the Contractor provides an approved security guard for any late or absentee security guards

• Remains available 24 hours a day, 7 days a week, 52 weeks a year including holidays by telephone to respond to any issues that may arise in the performance of the requirements as specified herein and respond to any such inquiries within 90 minutes and implement appropriate resolution actions

C. GENERAL SECURITY GUARD DUTIES

The general duties for each security guard include:

• Monitoring and patrolling the Library

• Ensuring a safe environment

• Assisting Kalamazoo Public Library staff in enforcing the Library’s Rules of Conduct

• Be familiar and implement emergency procedures when necessary

• Managing incidents

• Escorting problem patrons to the exit

• Delivering ban notices to Library patrons, when necessary

• Enforcing Library bans, when necessary

• Completing incident and accident reports, as necessary

• Monitor security CCTV cameras/console

• Calling law enforcement or medical assistance, as needed

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• Assist staff in responding to medical emergencies

• Escort personnel to vehicles as requested

• Guards shall not be engaged in or conduct any personal business or business outside those described by the contract at any time while assigned to the post except during authorized breaks

• All breaks must be taken inside the branch building and officers will remain alert and available to respond to requests for assistance

D. SECURITY GUARD LIST

The Contractor will provide to Library Administration and update as necessary an approved Security Guard List which must include, but not be limited to the following information:

• Full Name: First, Middle, Last

• Photo: Current, face

• Address: Residence

• Phone Numbers: Contact

• MI Driver’s License: Current The Contractor will not place any guards at the Kalamazoo Public Library unless that guard is on the approved security guard list.

E. UNIFORMS AND EQUIPMENT The Contractor will furnish and provide well-maintained uniforms for each security guard. The Contractor will furnish and provide sufficient quantity of uniforms to allow for each security guard to have an appropriate number of change outs.

The Contractor will ensure that all uniforms are clean and well pressed and always looking professional. The Contractor will not allow security guards to substitute any of the above uniform articles.

Note: Any security guard that reports to their assigned post and does not have the appropriate uniform must be immediately (within 1-hour) replaced with an approved guard that has the appropriate uniform.

The Contractor will furnish a mobile telephone and carrier services for each security guard to use and ensure the mobile telephone is carried by the security guard at all times while on shift.

F. POST AND HOURS

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The current contract provides for security guard services as described in the chart below. Kalamazoo Public Library is requesting pricing based on the current services as option one.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total Hours

Supervisor 845-5pm 845-430pm 230-815pm 845-4pm 845-615pm - - 38.5

Central Guard 1 230-815pm 9-3pm 9-230pm - - - 1245-5pm 21.5

Central Guard 2 - 230-815pm 9-3pm 9-3pm 9-615pm 945-515pm - 34.5

Central Guard 3 2-815pm 5-815pm 5-815pm 5-815pm

945-515pm 23.5

Eastwood Guard 2-8pm 2-6pm 2-6pm At Central 230-815pm 1-5pm - - 31.25

Powell Guard - 2-8pm 2-6pm 2-6pm 1-5pm 945-215pm - 22.5

Washington Square 2-6pm 2-6pm 2-8pm 2-6pm 1-5pm - - 22

Oshtemo 2-8pm 2-8pm 10-6pm 10-6pm 10-2pm - - 36

G. POST ORDERS

Within fifteen (15) days of the effective date, Contractor shall deliver draft comprehensive Post Orders for Library Administration review and approval. Contractor will prepare completed and approved Post Orders within ten (10) days of receipt. Post Orders shall include, but are not limited to:

• General safety procedures

• Emergency procedures

Investigation, incident, and emergency report procedures

• Shift patrol procedures

• Communication procedures

• Dress and grooming standards

• Training procedures including harassment training

• Photographs and diagrams of each site

H. MINIMUM SECURITY GUARD WAGES

Proposers are required to submit proposals that meet the below minimum security guard wages. Proposals that do not meet these requirements shall be determined to be non-responsive. Wages

Security Supervisor: Minimum hourly wage of $18.50

Security Guard: Minimum hourly wage of $16.00

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I. STAFFING PLAN Contractors must submit a staffing plan adequate to meet hours defined above that is comprised of full-time and part-time employees. Understaffing of guards will not be tolerated and may be cause for termination of the contract.

J. USE OF LIBRARY EQUIPMENT At no time shall assigned personnel use the Library telephones or other equipment for non-the Library or personal business without prior approval by the Library. Unauthorized use of any the Library equipment may be cause to terminate the guard from the Library assignment.

7. Billing and Invoicing A. PAYMENT TERMS

Contractor shall submit a correct and complete invoice(s) to the Library. Payment terms are Net 30 days or best offer, after receipt of service and correct invoice.

B. AGREEMENT RATES The Agreement rates shall remain firm and fixed for the Term of Agreement, including the three (3) option years. It is the responsibility of the Proposer, in calculating the proposal price, to take into consideration the possible escalation of material, labor and other costs during the term of the Agreement. The Library reserves its exclusive right to amend the Agreement to increase or decrease hours of service or level of staffing.

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Appendix A: Pricing Schedule

Unarmed Services

Estimated Annual Hours

Description Hourly Cost to KPL Annual Cost

9,945 Security Guard $ $

2,002 Security Supervisor $ $

Total: $

Description Overtime Hourly

Cost to KPL Annual Cost

Security Supervisor $ $

Security Guard $ $

All costs associated with the proposal must be included. The Library relies on the Proposer to assure that

all charges to complete the scope of work are submitted in the proposal and that there are no hidden

costs or charges that will be incurred by the Library.

No additional fee will be paid for a reasonable number of changes or minor additions to the scope of

work during the implementation process.

No payments will be made for any other services unless written authorization is received from the

Library prior to the commencement of any such work.

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Appendix B: Non-Collusion Affidavit RFP Number: _____________ RFP Description: ____________________________

I state that I am ___________________ of _________________________________

(Title) (Name of Firm)

and that I am authorized to make this affidavit on behalf of my Firm, its Owner, Directors, and

Officers. I am the person responsible in my firm for the price(s) and the amount of the bid.

I state that:

1. The price(s) and the amounts of this bid have been arrived at independently and without

consultation, communication or agreement with any other Contractor, bidder, or potential bidder.

2. Neither the price(s) nor the amount of the bid, and either the approximate price(s) or the

approximate amount of the bid, have been disclosed to any other firm or person who is a bidder or

potential bidder, and they will not be disclosed before the bid opening.

3. No attempt has been made or will be made to induce any firm or person to refrain from bidding

on this contract, or to submit a bid higher than this bid, or to submit any intentionally high or

noncompetitive or other form of complementary bid.

4. The bid of my firm is made in good faith and not pursuant to any agreement or discussion with,

or inducement from, any firm or person to submit a complementary or noncompetitive bid.

5. _______________________________, its affiliates, subsidiaries, officers, directors and

employees are not currently under investigation by any governmental agency and have not in the

last four years been convicted or found liable for any act prohibited by State or Federal law in any

jurisdiction, involving conspiracy or collusion with respect to bidding on any public contract, except

as follows:

_________________________________________________________________________________

_________________________________________________________________________________

______________________

SIGNATURE OF PERSON SUBMITTING BID

______________________________________

BID NOTARY’S SIGNATURE

Subscribed and sworn to before me this _____ day of _________________, 20__ in and

for _________________ County.

My commission expires: _________________________

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Appendix C: References

Proposers shall provide three (3) references for services outlined in this RFP. References shall be from projects of similar size and scope as the Library. These services should have been provided within the past three (3) years.

Reference #1

Company Name

Contact Person

Address

Phone Number

Email

Year of Experience

Reference #2

Company Name

Contact Person

Address

Phone Number

Email

Year of Experience

Reference #3

Company Name

Contact Person

Address

Phone Number

Email

Year of Experience

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Appendix D: Rules of Conduct for Library Use

These Rules of Conduct were adopted by the Board of Trustees of the Kalamazoo Public Library to promote a quiet, safe, attractive, sanitary, and orderly atmosphere and to ensure every person’s ability to use the Library and Library materials to the maximum extent possible and to have reasonable access to Library facilities without unreasonable interference from any other person. Any person violating any of these Rules may be asked to leave the Library for the remainder of the day, or for a longer period of time under the circumstances described below. Any person who refuses to leave the Library after being requested to do so for violating these Rules, or who returns to the Library prior to the authorized time, will be subject to arrest and prosecution for trespass. These Rules apply to all Library facilities, including but not limited to the Central Library and Branch Libraries.

Persons using Library facilities shall not 1. Make loud or unnecessary sounds or noises which disturb other persons or Library

staff. 2. Harass, intimidate, threaten or assault any person, including Library staff, by word or

act, or by behaving in a manner which can be reasonably expected to interfere with any other person’s use of the Library. Examples of such behavior include, but are not limited to, fighting, assault and or battery upon another person, staring at another person, following another person, singing or unwelcomed talking to others or in monologues, or any other behavior that is intimidating, hostile, offensive, or adversely impacts a person’s use of the Library.

3. Use tobacco products or electronic substitutes. 4. Consume food. Beverages in capped or covered containers are allowed. Food or

beverages may be consumed at Library events when authorized. 5. Enter into or remain in the Library without footwear. 6. Sleep, solicit or beg. 7. Possess any weapon or item used as a weapon, except for law enforcement, security

personnel, and as may be permitted by law. 8. Damage or steal Library or personal property. 9. Possess, consume, or be under the influence of any intoxicant or any controlled

substance, except as may be authorized by prescription. 10. Bring any animal into the facilities, except service animals (as defined by the Americans

with Disabilities Act) and animals brought into the Library in connection with Library programs.

11. Throw anything, spit, leave debris or waste materials in any place other than designated trash cans.

12. Present in any state of undress (excluding nursing parents), or engage in sexual activity. 13. Misuse of restrooms, which includes, but is not limited to, shaving, washing clothes

and bathing. 14. Fail to follow policies, directives, or procedures. 15. Refuse or fail to leave the Library facilities after having been requested to do so for

violating these Rules.

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Implementation of Policy Any person who violates these Rules, may be denied access to the Library by the Director (or their designee) upon notice to the person. While the denial period is intended to be progressive, i.e., 1st violation — up to 30 days, 2nd violation — up to 60 days, 3rd violation — up to 90 days, the Director may deny access for a period of up to one year or permanently for any violation that significantly disrupts the operation of the Library or significantly interferes with a patron’s or patrons’ right(s) to use the Library. Before denying access to any person the Director or designee shall inform the person of the reason and period of time they are being denied access and give the person a reasonable opportunity to state their response to the proposed denial. The Director or designee shall confirm the denial by written notice to the person if the person’s name and address are known. A person denied access may appeal to the Director within five (5) days of the date of the written notice. Additionally, a person denied such access may appeal the denial in writing to the Library Board at 315 S. Rose St., Kalamazoo, MI 49007, within ten (10) days of the date of the written notice. The appeal shall state the reasons why access to the Library should not be denied. An appeal to the Library Board shall not stay the Director’s denial. The Library Board shall provide the person with an opportunity to be heard before deciding the appeal and may affirm, modify, or reverse the Director’s denial. A person who has been denied access permanently may re-apply to the Board for access after a period of one year. The petition shall set forth the reasons the person believes reinstatement is justified. The Library Board shall provide the person with an opportunity to be heard before it makes its decision on the petition for reinstatement. The Library Board may deny, grant, or grant with conditions the petition for reinstatement. Policy adopted August 27, 1990 Revisions adopted June 22, 1998; February 24, 2003; March 24, 2003; September 25, 2006; January 25, 2010; June 23, 2014; April 15,2021. Updated: July 27, 2021.

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Appendix E: Signature Page Prices quoted shall remain firm for 90 days or bid award whichever comes first, except the successful bidder(s), whose prices shall remain firm for the entire contract period. The contract shall commence on date of award. NOTE: The undersigned has checked the bid figures carefully and understands that he/she shall be responsible for any error or omission in this bid offer and is in receipt of all addenda as issued. COMPANY NAME: ___________________________________________________________________ ADDRESS:__________________________________________________________________________

City State Zip TAX ID: __________________________ TELEPHONE NUMBER: (___) ______________ FAX NUMBER: (___) ____________ E-MAIL ADDRESS: ___________________________________________________________________ PAYMENT TERMS: ___________________________ ACKNOWLEDGEMENT: I, ______________________________________, certify that I have read the INSTRUCTION TO BIDDERS and that the bid proposal documents contained herein were obtained directly from the Detroit Public Library or MITN website, www.bidnetdirect.com, and is an official copy of the Authorized Version. COMPANY REPRESENTATIVE’S NAME: __________________________________________________________________________________ (Print) SIGNATURE OF AUTHORIZED COMPANY REPRESENTATIVE: __________________________________________________________________________________ (Signature) (Date)