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Title of the project: Improvement of Energy Efficiency through an Inter- Municipal Management Network – Engagement of Energy Expert Tender Reference: EuropeAid/133-339/L/ACT/ME – 2013/335- 263/10 Location: Bar, Montenegro TECHNICAL PROPOSAL
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Title of the project: Improvement of Energy Efficiency through an Inter-Municipal Management Network – Engagement of Energy Expert

Tender Reference: EuropeAid/133-339/L/ACT/ME – 2013/335-263/10

Location: Bar, Montenegro

TECHNICAL PROPOSAL

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TECHNICAL PROPOSAL

Tender Reference: EuropeAid/133-339/L/ACT/ME – 2013/335-263/10

Title of the project: Improvement of Energy Efficiency through an Inter-Municipal Management Network – Engagement of Energy Expert

Location: Bar, Ulcinj, Budva, Kotor, Tivat, Cetinje and Podgorica, Montenegro

Place, date

to: Municipality of BarBulevar Revolucije 185000, BarMontenegro

One signed form must be supplied together with the two copies specified in the letter of invitation to tender, procurement notice and instructions to tenderers. The form must include a signed declaration using the annexed format from each legal entity making the application. All data included in this form must concern only the legal entity or entities making the application. For economic and ecological reasons, we strongly recommend that you submit your files on paper-based materials (no plastic folder or divider).  We also suggest you use double-sided print-outs as much as possible.

Any additional documentation (brochure, letter, etc) sent with the form will not be taken into consideration. Applications being submitted by a consortium (i.e., either a permanent, legally-established grouping or a grouping which has been constituted informally for a specific tender procedure) must follow the instructions applicable to the consortium leader and its members.

An economic operator may, where appropriate and for a particular contract, rely on the capacities of other entities, regardless of the legal nature of the links which it has with them. It must in that case prove to the contracting authority that it will have at its disposal the resources necessary for performance of the contract, for example by producing an undertaking on the part of those entities to place those resources at its disposal. Such entities, for instance the parent company of the economic operator, must respect the same rules of eligibility and notably that of nationality, as the economic operator.

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1 SUBMITTED BY

Name(s) of tenderer(s) Nationality1

Leader2

Member 2*

Etc …

[* Delete as applicable]

2 CONTACT PERSON (for this tender)

Name

Address

TelephoneFaxE-mail

1 Country in which the legal entity is registered.2 Add/delete additional lines for members as appropriate. Note that a subcontractor is not considered

to be a member for the purposes of this tender procedure. If this tender is being submitted by an individual tenderer, the name of the tenderer should be entered as 'leader' (and all other lines should be deleted).

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3 TENDERER'S DECLARATION(S)

As part of their tender, each legal entity identified under point 1 of this form, including every consortium member, must submit a signed declaration using this format.

In response to your letter of invitation to tender for the above contract, we, the undersigned, hereby declare that:

1. We have examined and accept in full the content of the dossier for invitation to tender with reference EuropeAid/133-339/L/ACT/ME – 2013/335-263/10. We hereby accept its provisions in their entirety, without reservation or restriction.

2. We offer to execute, in accordance with the terms of the tender dossier and the conditions and time limits laid down, without reserve or restriction, the following works:

Title of the project: Improvement of Energy Efficiency through an Inter-Municipal Management Network

Location: Bar, Ulcinj, Budva, Kotor, Tivat, Cetinje and Podgorica,

Montenegro

3. The price of our tender excluding VAT is included in the financial proposal.

4. NA

5. This tender is valid for a period of 90 days from the final date for submission of tenders.

6. If our tender is accepted, we undertake to provide a performance guarantee, as required by Article 8 of the contract.

7. Our firm/company [and our partners] has/have the following nationality:

<…………………………………………………>

8. We are making this tender [on an individual basis/as member of the consortium led by < name of the leader / ourselves >]. We confirm that we are not tendering for the same contract in any other form. [We confirm, as a member of the consortium, that all members are jointly and severally liable by law for the execution of the contract, that the lead member is authorised to bind, and receive instructions for and on behalf of, each member, that the execution of the contract, including payments, is the responsibility of the lead member, and that all members in the joint venture/consortium are bound to remain in the joint venture/consortium for the entire period of the contract's execution].

9. We are not in any of the situations excluding us from participating in contracts which are listed in section 2.3.3 of the Practical Guide to contract procedures for EC external actions and we have read its contents as specified in the Annex 1 to this technical proposal. In the event that our tender is successful, we undertake, if required, to provide the proof usual under the law of the country in which we are established that we do not fall into these exclusion situations. The date on the evidence or documents provided will be no earlier than 1 year before the date of submission of tender and, in addition, we will provide a statement that our situation has not altered in the period which has elapsed since the evidence in question was drawn up.

We also understand that if we fail to provide this proof within 30 calendar days after receiving the notification of award, or if the information provided is proved false, the award may be considered null and void.

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10. We agree to abide by the ethics clauses in Clause 28 of the letter of invitation to tender, procurement notice and instructions to tenderers and, in particular, have no conflict of interests or any equivalent relation in that respect with other candidates or other parties in the tender procedure at the time of the submission of this application. We have no interest of any nature whatsoever in any other tender in this procedure.

11. We will inform the Contracting Authority immediately if there is any change in the above circumstances at any stage during the implementation of the contract. We also fully recognise and accept that any inaccurate or incomplete information deliberately provided in this application may result in our exclusion from this and other contracts funded by the EU/EDF.

12. We note that the Contracting Authority is not bound to proceed with this invitation to tender and that it reserves the right to award only part of the contract. It will incur no liability towards us should it do so.

13. We fully recognise and accept that we may be excluded from tender procedures and contract, in accordance with the Section 2.3.4 of the Practical Guide to contract procedures for EC external actions, for a maximum period of 5 years from the date on which the infringement is established and up to 10 years in the event of a repeated offence within the 5 years of the above-mentioned date. Furthermore, we acknowledge that, should we made false declarations, committed substantial errors, irregularities or fraud, we shall also be subject to financial penalties representing 2 % to 10 % of the total estimated value of the contract being awarded. This rate may be increased to 4% to 20% in the event of a repeat offence within 5 years of the first infringement.

14. We are aware that, for the purposes of safeguarding the financial interests of the Communities, our personal data may be transferred to internal audit services, to the European Court of Auditors, to the Financial Irregularities Panel or to the European Anti-Fraud Office.

Name and first name: […………………………………………………………………]

Duly authorised to sign this tender on behalf of:[…………………………………………………………………………………… …]

Place and date: […………………………………………………………….………….]

Stamp of the firm/company:

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QUESTIONNAIRE

INSTRUCTIONS TO FILL IN THE QUESTIONNAIRE

1. All questions contained in the forms must be answered by the tenderer.

2. Additional sheets may be attached as necessary.

3. If a question does not apply to the tenderer, "not applicable" should be entered alongside with a brief explanation of why.

4. Every single page of each form must be numbered consecutively in the bottom right-hand corner.

5. Financial data and declarations presented by the tenderer must be given in euro.

6. If the requested supporting documents/certificates are not written in English, a translation into English must be attached.

7. Each member of a joint venture/consortium must fill in and submit every form.

8. Firms applying as a joint venture/consortium must also complete the Form “Data on Joint ventures” and attaching the requested documents.

9. The person signing this questionnaire guarantees the truthfulness and accuracy of all the statements made.

10. The accuracy of the answers to the questionnaire, their completeness and the attached documentation will be taken into account in the tender evaluation. The attention of tenderers is also drawn to the fact that the absence of some data may cause their non-compliance in the related item of evaluation.

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GENERAL INFORMATION ABOUT THE TENDERER3

4.1.1. Name of company ............................................................................................................................................................................................................................................................

4.1.2. Registered address ............................................................................................................................................................................................................................................................Telephone .............................. Fax................................. Telex........................... E-mail..............................................................

4.1.3. Names and nationalities of principals/directors and associates....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4.1.4. Type of company (natural person, partnership, corporation, etc.).............................................................................................................

4.1.5. Description of company (e.g. general civil engineering contractor)4.1.6. Company's nationality...........................................................4.1.7. Number of years experience as contractor

- in own country.......................- internationally......................

4.1.8. Registration details ...................................................................................................................................................................................Please attach copy of the registration certificate

4.1.9. Equity in the companyShares (%)........................................................................................................................................................................................................................

4.1.10. Name(s) and address(es) of companies involved in the project and whether parent/subsidiary/subcontractor/other:..............................................................................................................................................................................................................................................................................................................................

4.1.11. If the company is a subsidiary, what involvement, if any, will the parent company have in the project?...............................................................................................

4.1.12. Foreign companies must state whether they are established in the state of the Contracting Authority in accordance with applicable regulations (for information only)

Signature: ..................................................................................

(a person or persons authorised to sign on behalf of the tenderer)

Date:.....................

3 Please note, in case the tender is submitted by a Consortium (i.e. 2 or more companies in partnership), this form must be filled in by each partner.

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POWER OF ATTORNEY

Please attach here the power of attorney empowering the signatory of the tender and all related documentation. Please note, in case the tender is submitted by a Consortium (i.e. 2 or more companies in partnership), there is the need to provide one Power of Attorney per each partner indicating that the representative of the leader company is authorized to represent the consortium.

Signature: ..................................................................................

(a person or persons authorised to sign on behalf of the tenderer)

Date: .....................

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Economic and financial capacity of candidatePlease provide all of the information required by this form in Euro. Please note, in case the tender is submitted by a Consortium (i.e. 2 or more companies in partnership), there is the need to provide this information per each partner.

Annual turnover for each of the last three years

Leader or single applicant: Name of the Company: ………….

Year-3 Year-2 Last year

Euro

Signature: .................................................................................. Date: .....................

(a person or persons authorised to sign on behalf of the Company)

Partner 1: Name of the Company: ………….

Year-3 Year-2 Last year

Euro

Signature: .................................................................................. Date:…………….

(a person or persons authorised to sign on behalf of the Company)

Partner 2: Name of the company: ………….

Year-3 Year-2 Last year

Euro

Signature: ..................................................................................

(a person or persons authorised to sign on behalf of the company) Date: .....................

Consortium

Year-3 Year-2 Last year

Euro

Signature: ..................................................................................

(a person or persons authorised to sign on behalf of the tenderer) Date: .....................

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PROFESSIONAL CAPACITY OF CANDIDATE

Name of expert Proposed position Years of experience

Age Educational background

Specialist areas of knowledge

Experience in beneficiary

country

Languages and degree of fluency

(VG, G, W)

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Curriculum vitae (to be prepared per each proposed expert as per ToR)

Proposed role in the project:

Family name:

First names:

Date of birth:

Nationality:

Civil status:

Education:

Institution

(Date from - Date to)

Degree(s) or Diploma(s) obtained:

Language skills: Indicate competence on a scale of 1 to 5 (1 - excellent; 5 - basic)

Language Reading Speaking Writing

Membership of professional bodies:

Other skills: (e.g. Computer literacy, etc.)

Present position:

Years within the firm:

Key qualifications: (Relevant to the project)

Specific experience in the region:

Country Date from - Date to

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Professional experience

Date from - Date to Location Company& reference person4

(name & contact details)Position Description

Other relevant information (e.g., Publications)

4 The Contracting Authority reserves the right to contact the reference persons. If you cannot provide a reference, please provide a justification.

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Technical capacity of candidate

Please fill in the table below to summarise the main projects related to this contract carried out over the past 3 years by the legal entity or entities making this application. The number of references to be provided must not exceed 5 for the entire application.

Ref no (maximum 5)Project title of the

project executed by the Tenderer

Name of legal entity Country

Overall contract

value (EUR)5

Proportion carried out

by legal entity (%)

No of staff

providedName of client Origin of

fundingDates

(start/end)Name of consortium

members, if any

… … … … … … … … …

Detailed description of projectType of services provided, including, if applicable, the services and corresponding amounts indicated in the

Contract Notice's selection criteria

… …

5 The effect of inflation will not be taken into account.

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DATA ON JOINT VENTURES

Name ......................................................................................Managing board's address ....................................................................................................................................................Telex ..........................................................Telephone .........................Fax..................................E-mail.....Agency in the state of the Contracting Authority, if any (in the case of a joint venture/consortium with a foreign lead member )Office address .............................................................................................................................................................................Telex ..........................................................Telephone ..............................Fax.........................................Names of membersi) ..............................................................................................ii) ..............................................................................................iii) ..............................................................................................Etc. ............................................................................................Name of lead member....................................................................................................................................................................................................Agreement governing the formation of the joint venture/consortiumi) Date of signature: ................................................................ii) Place: ...................................................................................iii) Enclosure - joint venture/consortium agreementProposed proportion of responsibilities between members (in %) with indication of the type of the works to be performed by each..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Signature: ..................................................................................

(a person or persons authorised to sign on behalf of the tenderer)

Date: .....................

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Annex 1

TEXT OF THE SECTION 2.3.3 OF THE PRACTICAL GUIDE – GROUNDS FOR EXCLUSION6

Candidates or tenderers will be excluded from participation in procurement procedures if:

a) they are bankrupt or being wound up, are having their affairs administered by the courts, have entered into an arrangement with creditors, have suspended business activities, are the subject of proceedings concerning those matters, or are in any analogous situation arising from a similar procedure provided for in national legislation or regulations;

b) they have been convicted of an offence concerning their professional conduct by a judgment which has the force of res judicata; (i.e. against which no appeal is possible);

c) they have been guilty of grave professional misconduct proven by any means which the Contracting Authority can justify;

d) they have not fulfilled obligations relating to the payment of social security contributions or the payment of taxes in accordance with the legal provisions of the country in which they are established or with those of the country of the Contracting Authority or those of the country where the contract is to be performed;

e) they have been the subject of a judgment which has the force of res judicata for fraud, corruption, involvement in a criminal organisation or any other illegal activity detrimental to the EU's financial interests;

f) they are currently subject to an administrative penalty referred to in Article 96(1) of the Financial Regulation (BUDGET)/ Article 99 of the Financial Regulation (10th EDF).

Points (a) to (d) shall not apply in the case of purchase of supplies on particularly advantageous terms from either a supplier which is definitively winding up its business activities, or the receivers or liquidators of a bankruptcy, through an arrangement with creditors, or through a similar procedure under national law.

The cases referred to in point (e) applicable are the following:

1) cases of fraud as referred to in Article 1 of the Convention on the protection of the European Communities' financial interests drawn up by the Council Act of 26 July 1995;

2) cases of corruption as referred to in Article 3 of the Convention on the fight against corruption involving officials of the European Communities or officials of Member States of the European Union, drawn up by the Council Act of 26 May 1997;

3) cases of participation in a criminal organisation, as defined in Article 2(1) of Joint Action 98/733/JHA of the Council;

4) cases of money laundering as defined in Article 1 of Council Directive 91/308/EEC.

Interpretation of the Grounds for exclusion

The Contracting Authority will accept, as satisfactory evidence that the tenderer is not in one of the situations described in (a), (b) or (e) the production of a recent extract from the judicial record or, failing that, a recent equivalent document issued by a judicial or administrative authority in the country of origin or provenance showing that those requirements are satisfied. The Contracting

6 Please note that the part on the language of the documents is partly amended to take into account the limited language knowledge of the local Contracting Authorities.

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Authority shall accept, as satisfactory evidence that the candidate or tenderer is not in the situation described in (d), a recent certificate issued by the competent authority of the State concerned. Where no such document or certificate is issued in the country concerned7 and for the other cases of exclusion listed above, it may be replaced by a sworn/solemn statement made by the interested party before a judicial or administrative authority, a notary or a qualified professional body in its country of origin or provenance.

The Contracting Authority should take into account that, as a rule, the exclusion criteria are related to the legal entity/ natural person who acts as a tenderer and not to its representatives in case of legal entities. However, depending on the national legislation of the country in which the tenderer or candidate is established and where considered necessary by the Contracting Authority or where the Contracting Authority has doubts concerning the personal situation, the above documents may also relate to the natural persons including company directors or any person with powers of representation, decision-making or control in relation to the candidate or tenderer. Whenever one tenderer, due to its nature (for instance, national public administrations and international organisations), cannot fall into some of the categories above and/or cannot provide the documents indicated above, a simple declaration explaining their situation will suffice.

Tenderers must sign their applications including the declaration that they do not fall into any of the categories cited above.

Tenderers who have been notified the award of a contract following an open procedure must supply the proof usual under the law of the country in which they are established that they do not fall into the categories listed above. The date on the evidence or documents provided must be no earlier than 1 year before the date of submission of the tender. Tenderers must, in addition, provide a statement that their situation has not altered in the period that has elapsed since the evidence in question was drawn up. If the supporting documents are not written in English, they will have to be translated in English.

The required proof documents shall be submitted by the tenderer and their consortium members. The documents may be originals or copies. The original documents shall be available upon request by the Contracting Authority.

If sub-contractors are used, they may not be in any of the exclusion situations either.

Whenever requested by the Contracting Authority, the successful tenderer/contractor shall submit a declaration from the intended subcontractor that it is not in one of the exclusion situations. In case of doubt on this declaration of honour, the Contracting Authority shall request the documentary evidence as mentioned above.

Contracts may not be awarded to tenderers who during the procurement procedure:

a) are subject to a conflict of interest;

b) are guilty of misrepresentation in supplying the information required by the Contracting Authority as a condition of participation in the contract procedure or fail to supply this information;

c) find themselves in one of the situations of exclusion for this procurement procedure.

7 Information on the certificates that the Member States have reported, regarding which types of proof documents are issued/acceptable in each of the Member States, is available on the following website of DG Internal Market: Certificates issued on the eligibility of tenderers and official lists of economic operators -http://ec.europa.eu/internal_market/publicprocurement/2004_18/index_en.htm. Please note that this list is indicative

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Annex 2

EVALUATION GRIDS

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Summary of the received tenders

Contract title :

Improvement of Energy Efficiency through an Inter-Municipal Management Network - Engagement of Energy Expert

Tender reference : EuropeAid /133-339/L/ACT/ME – 2013/335-263/10

Tend

er e

nvel

ope

num

ber

(Lead)8 tenderer name

When received9

Rec

eive

d by

10

(Ini

tials

)

Number of copies (3 copies

are requested)

With

in d

eadl

ine?

(Yes

/No)

Tend

er p

acka

ge(s

) du

ly s

eale

d?

(Yes

/No)

Tech

nica

l pro

posa

l en

velo

pe in

clud

ed?

(Yes

/No)

Fina

ncia

l Pro

posa

l en

velo

pe

incl

uded

? (Y

es/N

o)

Oth

er re

leva

nt

issu

es o

r Rel

evan

t re

mar

ks

expl

aini

ng th

e ov

eral

l dec

isio

n Overall decision

(Accept / Reject)

8 For tenders submitted by a consortium9 Time to be recorded only for tenders received on the last date for submissions10 Name(s) of person(s) receiving tenders:

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ADMINISTRATIVE AND TECHNICAL COMPLIANCE GRID

Project title : Improvement of Energy Efficiency through an Inter-Municipal Management Network - Engagement of Energy Expert

Tender reference: EuropeAid/133-339/L/ACT/ME–2013/335-263/10

Tend

er e

nvel

ope

num

ber

Tenderer name

Tend

erer

’s d

ecla

ratio

n(s)

(Yes

/No)

Nat

iona

lity

rule

re

spec

ted?

(yes

/No)

Gen

eral

info

rmat

ion

abou

t the

tend

erer

Pow

er o

f atto

rney

for t

all

the

invo

lved

ent

ities

(Yes

/No)

Lang

uage

as r

equi

red?

Dat

a an

d A

gree

men

t on

join

t ven

ture

(Yes

/No/

Not

A

pplic

able

)

Econ

omic

and

fina

ncia

l ca

paci

ty o

f can

dida

te a

s re

ques

ted

(Yes

/No)

*

Prof

essi

onal

cap

acity

of

cand

idat

e as

requ

este

d (y

es/N

o)*

Tech

nica

l cap

acity

of

cand

idat

e as

requ

este

d (y

es/N

o)*

Ove

rall

deci

sion

?(A

ccep

t / R

ejec

t)

1

2

3

4

5

*Data to be provided by the evaluators on the basis of the detailed technical compliance grid

Chairperson's name Secretary’s name

Chairperson's signature Secretary's signature

Date Date

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DETAILED TECHNICAL COMPLIANCE GRID

Project title: Improvement of Energy Efficiency through an Inter-Municipal Management Network - Engagement of Energy Expert

Tender reference: EuropeAid/133-339/L/ACT/ME-2013/335-263/10

Letter of invitation to tender

Item TENDER ENVELOPE NUMBER / TENDERER’S NAME

Clause17.1.1 Economic and financial capacity of candidateThe average annual turnover of the tenderer in the past 3 years must be at least EUR 150.000 (one hundred and fifty thousand Euro). In the case of a tender submitted by a consortium the economic and financial criteria required must be fulfilled as follows:- the leader must meet minimum 60%, and- the consortium as a whole must meet 100% of the above mentioned criteria.

Clause17.2 Professional capacity of candidateThe Company/Contractor will have to provide a team of experts able to express the following professionalities with minimum three (3) permanent employed staff in company and minimum five (5) years professional experience in energy sector as mandatory requirements.

General qualification and experience:Team Leader: Organization, coordination, communication and managing of the project

He/she shall possess University Degree in Engineering, Technical Sciences or

relevant, directly related discipline or equivalent Minimum 10 years of working experience Excellent working knowledge of English, both written and

spoken Reference in the field of energy and activities similar with the

requested ones Experience in development of strategic documents for energy

sector would be considered an asset

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Energy related work within projects financed by International Organisations or for International Organizations.

Knowledge of managing Human Resources

Expert 1: Identification of actual energy production and consumption He/she shall possess University Degree in in Engineering, Technical Sciences or

relevant, directly related discipline or equivalent Excellent working knowledge of English, both written and

spoken Reference in the field of energy and activities similar with the

requested ones Reference in energy production and consumption calculation Advanced computer skills: MS Office (Word, Excel, MS

Project, MS Power point, MS Access), ArcGIS Desktop, Autodesk: AutoCAD, Programs for energy calculation KI Expert & ENSI software or similar 

Expert 2: Modeling of energy production and consumption He/she shall possess University Degree in in Engineering, Technical Sciences or

relevant, directly related discipline or equivalent Excellent working knowledge of English, both written and

spoken Reference in the field of energy and activities similar with the

requested ones Reference in energy modeling Advanced computer skills: MS Office (Word, Excel, MS

Project, MS Power point, MS Access), ArcGIS Desktop, Autodesk: AutoCAD, Programs for energy calculation KI Expert & ENSI software or similar 

Expert 3: Analysis of civil (residential and tertiary) and industry sector He/she shall possess University Degree in Engineering, Technical Sciences or

relevant, directly related discipline or equivalent Excellent working knowledge of English, both written and

spoken Reference in the field of energy and activities similar with the

requested ones Reference in analysis of civil and industry sector Advanced computer skills: MS Office (Word, Excel, MS

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Project, MS Power point, MS Access), ArcGIS Desktop, Autodesk: AutoCAD, Programs for energy calculation KI Expert & ENSI software or similar 

Expert 4: Greenhouse gasses calculation He/she shall possess University Degree in Engineering, Technical Sciences or

relevant, directly related discipline or equivalent Excellent working knowledge of English, both written and

spoken Reference in the field of energy and activities similar with the

requested ones Reference in GHG calculation in civil and industry sector

Expert 5: Economic analysis He/she shall possess University Degree in Economics, Management, Engineering,

Technical Sciences or relevant, directly related discipline or equivalent Economics (VII level)

Minimum 5 years of working experience Excellent working knowledge of English, both written and

spoken Reference in the field of energy and activities similar with the

requested ones Reference in economic analysis in energy sector

Team leader and all other expert engaged in performing local energy plan should have following professionalties:

Experience in the field of energy efficiency through projects development and implementation

Excellent understanding of concepts of energy efficiency and energy management

Good organizational, coordination, communication and managing skills

Years of professional experience: the team is made of six experts. The team leader must have at least 10 years of experience and the Expert 5 at least 5 years of experience. The other four experts must have at least 10 years of experience (two members) and at least 5 years of experience (two members).

Page 23: …  · Web viewAdvanced computer skills: MS Office (Word, Excel, MS Project, MS Power point, MS Access), ArcGIS Desktop, Autodesk:

The contractor will have to select additional professionals (if necessary) to properly implement this service contract.

Clause17.3 Technical capacity of candidate1. The tenderer must have successfully completed as prime contractor, over the last 3 (three) years (Timing ending on the deadline for submission of this tender) at least 2 (two) contracts of similar complexity and similar value.

Tender accepted (A) for further evaluation or rejected (R)

Name Signature

Voting Member _________________________________________________ _________________________________________

Voting Member _________________________________________________ _________________________________________

Voting Member _________________________________________________ _________________________________________

Date: _________________________________________________ _________________________________________


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