GENERAL REGISTRATION PROCEDURE & GUIDELINES Issuance of a notice to proceed accreditation including requirements Supplier will deliver accomplished Vendor Information Sheet and Required Documents (originals and photocopies, see attachment), to Dun & Bradstreet Philippines Inc. o Makati Office: Ground Floor Convergys One Building (Mail & More Flagship Store) 6796 Ayala Avenue cor Salcedo Street, Makati City dunsnumber@dnb.com.ph Contact Persons: Cynthia Galope GalopeC@DNB.com.ph (02) 750.0082 (02) 774.8342 o Cebu Office: 5 th Floor Krizzia Building Gorordo Avenue Lahug, Cebu City [cebu@dnb.com.ph] Contact Person: Sheila Negare NegareS@DNB.com.ph (032) 233-6053 *** For Provincial Suppliers: Option to send Supplier Registration Form and Certified True Copies of pertinent requirements via courier. 3. Payment The processing fee shall be paid at the Dun & Bradstreet Philippines Inc. upon submission of documents. The processing fee may also be paid thru bank. Please attach a copy of the deposit slip upon submission of documents An official receipt will be issued upon confirmation of payment 4. Issuance of Letter of Accreditation (issued by Globe Telecom) Globe Telecom shall advise the supplier either thru email when their evaluation process has been completed. *** Note: Only Suppliers with fully accomplished Supplier Registration Forms submitted with complete and verified documents and have paid will be processed. Page 1 of 16
LIST OF REQUIRED DOCUMENTS UNDER GLOBES ACCREDITATION PROCESS VENDOR INFROMATION SHEET (see attached) UNDERTAKINGS (see attached) 3. E-SOURCING ENROLLMENT FORM (see attached) 4. BUSINESS REGISTRATION 5. For Corporations: i. SEC Registration (i.e. SEC Certificate, Articles of Incorporation and By Laws) ii. General Information Sheet iii. Competent evidence of identity Authorized signatories - Any government issued ID with picture Company Community Tax Certificate iv. Board Resolution / Secretary certificate of authorized signatories For Sole Proprietor: i. DTI Registration ii. Business Permit / Mayor s Permit iii. Owner s Identification ** valid IDs include: Driver s License, Passport or NBI Clearance 6. PROOF OF BUSINESS ADDRESS Any of the following: - Transfer Certificate Title (TCT) - Lease Agreement - latest Utility Bill 7. FINANCIAL STATEMENTS o o Audited FINANCIAL STATEMENTS for the last three (3) consecutive years (with proof of BIR Payment and SEC stamp) Updated interim FINANCIAL STATEMENT For Sole Proprietor: Include a copy of Annual Income Tax Return (BIR Form 1702) For NEW Companies: Please provide Financial Forecast for the next 3 consecutive years (i.e. Balance Sheet and Income Statement) 8. BIR CERTIFICATE (BIR Form 2303 or 1556) 9. Business Permit 10. Regulatory Requirements For Contractors (at least an A License from the Philippine Contractor s Accreditation Board (PCAB) For Couriers/Forwarders: Department of Transportation and Communication (DOTC) For Brokers: Port Accreditation Certificate For Manpower Services : Department of Labor and Employment (DOLE) For VAS providers (NTC permit) 1 Court Cases (if any) 1 TABLE OF ORGANIZATION with names 13. COMPANY PROFILE (based on below outline) i. Product / Services Offered (including prices/rates) Market share Who are your competitors? Comparative pricing Advantage over competitors ii. Company Background iii. iv. Competence and Capability to Deliver Track Record Top 3 Customers Contract duration and amount with top 3 customers Total no. of years in business with top 3 customers v. Support System Customer service support Quality control Business contingency plan Safety, Environment and security vi. vii. Site Tour/Visit (if necessary) Others 14. Related Party Disclosures ( holding positions or having relatives in Globe, or major competitors of Globe) 15. QUALITY MANAGEMENT DOCUMENTS ISO Certificates 16. Last 6 months SSS / Pag-ibig / Philhealth 17. Last 6 months utility billing statement (water, telco, power) 18. List of Machineries 19. List of Vehicles used for operation Page 2 of 16
UNDERTAKINGS In consideration of the accreditation as supplier of GLOBE TELECOM, I hereby unconditionally undertake the following: To hold with utmost confidence all information relative to the operation or otherwise of GLOBE TELECOM disclosed to the vendor during the CUSTOMER VENDOR relationship of GLOBE TELECOM and the Vendor, including but not limited to technical information, specifications, drawings, documentation and know-how of every kind and description whatsoever disclosed by GLOBE TELECOM (the information ), except insofar as it may be in the public domain or to be established to have been independently developed and so documented by the Vendor or obtained from any person not in breach of any confidentiality obligations to GLOBE TELECOM, is the exclusive property of GLOBE TELECOM, and the other party except as specifically authorized in writing by GLOBE TELECOM, or as may be permitted shall treat and protect the information as confidential, shall not reproduce the information except to the extent reasonably required for the performance of the Vendor s obligations to GLOBE TELECOM, shall not divulge the information in whole or in part to any third parties, and shall use the information only for purposes necessary for the performance of Vendor s Information. The Vendor shall disclose the information only to those of its employees and agents who shall have a need-to-know the information for purposes of complying with Vendor s obligations. To submit annually copies of the Vendor s audited financial statements and an updated Vendor Information Sheet as soon as they are available and to advise GLOBE TELECOM of any changes in the corporate organization, beneficial ownership of the Vendor. Changes must be stated in writing and provided on official company stationary. 3. To strictly abide by the rules and procedures promulgated by GLOBE TELECOM particularly on but not limited to bidding procedures. 4. To make available all pertinent documents requested by GLOBE TELECOM. 5. To obtain prior written consent of GLOBE TELECOM if the Vendor intends to publish, advertise, promote, and issue press release or other publicity matters with regard to its accreditation with GLOBE TELECOM. Likewise, I warrant that the data I provided in the Vendor Information Sheet are true and correct and that any omission any misrepresentation with regards to the data provided therein, if later found to be untrue or uncorrect, I fully understand and agree that our Company shall be immediately deleted from the list of Accredited Vendors of Globe Telecom and Innove Communication without need of further notice. Furthermore, in such event, any pending project or order shall ipso facto be terminated or withdrawn at the option of Globe Telecom. The undersigned hereby understands that any violation of the foregoing shall not mean only deletion from the list of GLOBE TELECOM Accredited Vendors but likewise may be held liable for any damages, whether directly or indirectly incurred as a result of the supplier s non-compliance with this undertaking. I,, in my capability as (Full Name) (Official Title) of acknowledge that I am duly authorized and I have full authority to sign (Company Name) this undertaking and bind. (Company Name) Printed name over signature Page 3 of 16 date (mm/dd/yyyy)
E-SOURCING ENROLLMENT FORM Account Group: Local Supplier Local Contractor Foreign Contractor Service Provider with Foreign Partner COMPANY NAME: ADDRESS DETAILS: Head Office Telephone: Fax Number: ADDRESS DETAILS: Branch Office Telephone: VAT Reg. No.: P.O. Box: Fax Number: Tax Identification No. Postal Code: OWNERSHIP: % Filipino % Other Nationality COMPANY CLASSIFICATION (for GOODS Supplier Only): Manufacturer Importer Dealer Trader N/A SUPPLIER OFFICIAL REPRESENTATIVE INFORMATION: First Name: Middle Name: Last Name: Position: Mobile No.: E-Mail: Effective Date of Access Privilege: Date Category/Service Offered: Accredited Unaccredited Page 4 of 16
USER ID AND PASSWORD ACKNOWLEDGEMENT AND UNDERTAKING Upon receipt and initial use of the USER ID and PASSWORD which will be sent to me through my official e-mail address from the e- Sourcing Portal system, I hereby signify my agreement to be bound by the terms and conditions set forth below: I shall take the full responsibility of securing and safeguarding the secrecy and strict confidentiality of my USER ID and PASSWORD. I shall not allow anyone to perform any activity with my USER ID; I shall not disclose my USER ID and PASSWORD to any person under any circumstances except for official company purposes. If proven that I have violated the foregoing, and the said USER ID and PASSWORD were used to execute unauthorized transaction on the e-sourcing portal, such act may be used by Globe Telecom Inc. in disqualifying the company I represent from joining any, or all future bid/auction events. Further, I shall be liable to my employer pursuant to the company policy I fully understand that access to Globe Telecom e-sourcing Portal information systems is a privilege which may be changed or revoked at the sole discretion of Globe Telecom management, and which can be terminated through an official advice from my company/employer. SUPPLIER REPRESENTATIVE UNDERTAKING: I HAVE READ AND UNDERSTOOD THE FOLLOWING POLICIES: A. USER ID AND PASSWORD ACKNOWLEDGEMENT AND UNDERTAKING (see above): B. TERMS AND CONDITION OF THE USING THE PORTAL (see below): Signature over Printed Name Date Supplier warrants that by signing this enrollment form, the company, represented herein by Supplier s Official Representative is bound by the Terms and Conditions (see below) of Globe Telecom E-Sourcing exercise: CONFORME: PRESIDENT / CEO Signature over Printed Name Date For Globe Telecom Supplier Management Section Use Only Assign User ID: Remarks: Processed by: e-sourcing System Admin. Signature over Printed Name Date Remarks: Approved by: Head, Supplier Management Signature over Printed Name Date. Page 5 of 16
E-SOURCING STANDARD TERMS & CONDITIONS TERMS AND CONDITIONS It is mandatory for the bidder, hereinafter referred to as the Supplier, to accept the terms and conditions of the item(s) for bidding as specified (if any) before downloading the Bid document/attachments; failing which the e-sourcing Portal shall not allow the bidder to download those said documents. ASSIGNMENT OF SUPPLIER REPRESENTATIVE The bidder shall be represented by only one authorized account representative who can legally bind the former with the submission of commercial and technical tenders on the e-sourcing Portal at any given time. The Bid and Auction invitation shall be transmitted to the authorized account representative by the Commodity Specialist (buyer) of Globe Telecom Inc. (GLOBE) or any of its subsidiaries. Authentication ticket, which is a requirement to the confirmation and participation to an Auction event, shall also be transmitted to the e-mail address of the designated bidder representative. In case there is a need for the bidder to replace his current account representative (e.g. in case of termination or resignation), a formal written request to this effect should be accomplished and transmitted to the Head of Supplier Management Section of GLOBE. This action shall not, in any way, invalidate any posted/submitted tender made on the e-sourcing Portal prior to the effective date of the replacement of the account representative. The effective date of replacement of the bidder s account representative must have the approval of the Head of Supplier Management Section of GLOBE. In no case shall the bidder be without an authorized representative defined on the e-sourcing Portal, else, the former continued use of the system shall be suspended until such time an authorized representative is appropriately assigned. 3. COST OF PARTICIPATION The bidder shall bear all the costs associated with the preparation and submission of its bids, including the hardware, software, and communication requirements (Internet) to connect to the e-sourcing Portal, and GLOBE, will in no case be responsible or liable for these costs, regardless of the conduct or outcome of the bidding process. 4. BIDDING DOCUMENT The supplier is expected to examine all instructions, forms, terms and conditions and technical specifications in the Bid or Auction invitation posted on the portal. Failure to furnish all information required by the Bid/Auction Event or submission of a bid not substantially responsive to the requirements of the Bid/Auction Event, in every respect will be the bidder s risk, and may result in the rejection of its tender. Bidder should strictly submit his bid as per instruction, failing which will be considered as nonresponsive. 5. DOWNLOADING THE TENDER DOCUMENT (RFX) Bid tenders posted on the portal are considered legally binding proposals on the bidder for which subsequent purchasing documents (e.g. contracts, Purchase Orders) can be referenced or completed against. Bid tender documents posted on the portal shall prevail over all other documents presented for the Bid item (e.g. manual hardcopy). Copies procured by any other source will be considered invalid. All document attachments to Bid/Auction invitations, must be password- protected and computer virus - free; preferred format is in Acrobat (i.e. PDF). 6. AMMENDMENT/CANCELLATION OF BID/AUCTION EVENT GLOBE, at any time, may, for any reason, whether at its own initiative, in response to a clarification requested by a prospective bidder, or to provide bidders reasonable time to prepare responsive tenders, extend the submission deadline of a Bid Event. GLOBE, reserves the right at any time, for any reason to withdraw or amend the Bid item posted on the portal. Amendment to the requirements of the Bid Event shall be coursed through the e-sourcing Portal through its clarification feature (a function allowing the modification of bid requirements from the GLOBE, or tender from the bidder). GLOBE, reserves the right, at any time, for any reason, to cancel an Auction event posted on the portal prior to its scheduled start date and time. The bidder cannot request GLOBE to suspend an ongoing Auction event for any reason, whether technical in nature (e.g. ISP service unavailable) or otherwise. 7. PERIOD OF VALIDITY Commercial tender for a Bid Event shall remain valid for a period of ninety (90) days from date of bid opening prescribed by GLOBE. A bid valid for a shorter period shall be rejected by GLOBE as non-responsive. In exceptional circumstances, GLOBE may solicit the Bidders consent to an extension of the validity period. The request and response thereto shall be made in writing or fax. The bidder may refuse the request. A bidder granting the request will not be required or permitted to modify its bid. For an Auction event, the price quoted must be valid and firm for a period of ninety (90) days. No change in price quoted shall be allowed after bid submission unless negotiated by GLOBE or any of its subsidiaries. Page 6 of 16
8. BID CURRENCY The prices in the bid document shall be expressed in United States Dollar (USD) or Philippines Peso (PHP). 9. DEADLINE FOR SUBMISSION OF BIDS Submission of Bid must be completed before the expiry time mentioned in the tender schedule. GLOBE may, at its discretion extend this deadline for submission of bids, in which case all rights and obligations of the GLOBE and bidder previously subject to the deadline will thereafter be subject to the deadline as extended. 10. LATE BIDS The e-sourcing Portal will not allow any bidder to place their tender after the bid submission deadline. The system, except during the clarification stage, does not allow changes or updates to the Bid Event created by GLOBE, nor tender submitted by the bidder after the submission deadline. 1 MODIFICATION AND/OR WITHRAWAL OF BIDS The bidder can modify their bids only before the deadline schedule. The e-sourcing Portal will not allow any bidders to modify their bids after the expiry of schedule. No bidder shall be allowed to withdraw the bid, if bidder happens to be the successful bidder. 1 CONFIDENTIALITY Bids are confidential. Except for GLOBE assigned Commodity Specialist, who created the Bid Event on the portal, bidders are not allowed to discuss their commercial tender with any other GLOBE or any of its subsidiaries employee, with other suppliers, or with any other third party during the Bid Event. GLOBE shall not discuss, nor reveal the commercial tender, submitted by a particular bidder with another, during or after the conclusion of the Bid event. 13. BID OPENING & EVALUATION GLOBE will open the bids online; bidders may view the status of their submissions on the portal. Bids that have been evaluated as responsive, as per the technical and other qualification criteria as underlined in the bid document shall be endorsed for approval on the portal. The endorsement of such tender, however, does not automatically signify the award of a purchase. 14. CLARIFICATION OF BIDS To assist in the examination, evaluation and comparison of bids, GLOBE may, at its discretion, engage the bidder in a clarification phase. This shall allow the bidder to post other pertinent documents, or provide further details on his initial response in the portal. The bidder may only enhance/modify his commercial tender upon the advice of GLOBE on the portal. Changes made on the original commercial tender by the bidder without the advice of GLOBE, may result in the bid being rejected for endorsement. In case of a substantial change in configurations/specifications on the original bid event, a new one having a different submission deadline may be created to supersede the existing invitation. The original Bid items shall be withdrawn and communicated on the portal. 15. PRELIMINARY EXAMINATION GLOBE will examine the bids to determine whether they are complete in documentation requirements, whether any computational errors have been made, whether required information have been provided, as mentioned in the bid document. The bid determined as not substantially responsive cannot be endorsed by GLOBE, nor can it be made responsive by the bidder by correction of the non-conformity. GLOBE may waive any minor informality or non-conformity or irregularity in a bid, which does not constitute a material deviation, provided such waiver does not prejudice to affect the relative ranking of any bidder. 16. CONTACTING GLOBE Any effort by a bidder to influence GLOBE in the evaluation, bid comparison, or contract award decision may result in the rejection of the Bidder s bid. GLOBE S decision will be final and without prejudice and will be binding on all parties. 17. BID ACCEPTANCE GLOBE reserves the right to accept or reject any bid and annul the bidding process, or even reject all bids at any time prior to award of contract, without thereby incurring any liability to the affected bidder or bidders or without any obligation to inform the affected bidder or bidders about the grounds for GLOBE S actions. GLOBE reserves the right to accept or reject any technology proposed by the vendor. GLOBE reserves the right to select more that one vendor keeping in view its large requirements. 18. PATENTS RIGHTS The supplier shall indemnify GLOBE against all third party claims of infringement of patent, trademark, or industrial design rights arising from use of Goods, or any part thereof. 19. ASSIGNMENT The bidder shall not assign, in whole or in part, its obligations to perform the conditions, and requisites stipulated on the technical and commercial bid tender he has posted on the portal, except with GLOBE S prior written consent. Page 7 of 16
VENDOR INFORMATION SHEET PRODUCT / SERVICES APPLIED FOR ACCREDITATION: REGISTERED BUSINESS NAME Corporate Name / Business Name Trade Style Previous Business Name Date of Name Change Business Hours Tax Identification Number Tax Payer Classification VAT-registered contractor/supplier Non-VAT contractors/supplier Tax Exempt Please indicate and submit proof PHYSICAL ADDRESS DETAILS Unit No / Floor Street Name City Province Building No. / Name Subdivision / Village Zip Code CONTACT DETAILS Area Code Telephone Number Fax Number Email Address Website LEGAL STRUCTURE / COMPANY TYPE Corporation Partnership Single Proprietorship Others (please specify) SEC REGISTRATION DETAILS Date Registered Date Started Operations Registration No. Shareholders / Partners Nationality Contributed / Subscribed Capital Page 8 of 16
Members of the Board/Top Officials Nationality Position For Corporations Authorized Capital Paid Up Capital As of (2009) Subscribed Capital Par Value DTI REGISTRATION DETAILS Date Registered Registered / Authorized Capital Registration No. BUSINESS PERMIT Date Registered Permit Number MAYOR S PERMIT Date Registered Permit Number CONTACTS Name Position Contact Details Administration Tel. no. Mobile no. E-mail Finance Tel. no. Mobile no. E-mail 3. Technical Tel. no. Mobile no. E-mail Page 9 of 16
BUSINESS ACTIVITIES Nature of Business Wholesaler Retailer Manufacturer Contractor / Service Others (please specify) Description of Line of Business Distributorship Agreement: Exclusive: Non-exclusive: Validity: Validity: List down major Product Lines or Brands: Product Line Brand Product Line Brand Sources of Raw Materials / Merchandise: Local % International % Imports From: Country % Country % Supplier s Reference Please list local suppliers including subcontractors and partners with whom you have current transactions up to the last 6 months as trade references: 3. 4. 5. Name of Supplier Contact Person Tel. Nos. Terms Market/Customers(s): Local % International % Exports to: Country % Country % Page 10 of 16
Customer s Reference Please list local customers with whom you have current transactions up to the last 6 months as trade references: 3. 4. 5. Name of Customer Contact Person Tel. Nos. Terms DESCRIPTION OF HUMAN RESOURCE Number of Employees Directors Active in Operations Manager(s) Rank and File Contractual TOTAL Employment Turnover Low Moderate High Benefits received: A. Pag-ibig, PHIC, SSS Yes No B. 13 th month pay Yes No C. Other medical benefits Yes No D. Others (please specify) COMPANY DETAILS Parent Company Name Complete Address Telephone Number Email Address Fax Number Representative Office in The Philippines (If Any, For Foreign Company) Name of the Firm/Company Address Telephone No. Email Address Fax No. Website/s Page 11 of 16
Branches Address Premises Used As No. of Employees Subsidiaries Subsidiary Company Name Address No. of Employees % Equity held FACILITIES LAND Owned Renting / Lease Area Sq. Meters Monthly Rental Lease Expiry (MM/YY) BUILDING Owned Renting / Lease Area Sq. Meters Monthly Rental Lease Expiry (MM/YY) LOCATION Residential Commercial Industrial Mixed PREMISES USED AS ACCESSIBILITY TO PUBLIC UTILITIES Headquarters Sales Office Warehouse Plant Admin Office Branch/Outlet Others Yes Route: No SECURITY Specify what security arrangements exist for securing access points (i.e. Locks, bars, burglar alarms, etc.) a. Main doors b. Other entrance doors c. Windows d. Overall protection of premise Page 12 of 16
FINANCIAL INFORMATION a. Total Assets b. Total Liabilities Net Equity c. Current Assets d. Inventories e. Current Liabilities Applicant Parent Company (if applicable) Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 BANK INFORMATION Bank Branch Contact Person Contact No. Account Type INSURANCE INFORMATION Employers Liability Insurance All Risk Marine Cargo Insurance (Ocean and Inland) Contractor s All Risk Insurance Third Party Liability Insurance Workmen s Compensation Insurance INSURANCE COMPANY QUALITY MANAGEMENT ISO 9000/9002 QMS or equivalent Quality Management ISO 18000 or equivalent/health and safety programs 3. ISO 14000 or equivalent/environment programs 4. DENR permits/certifications 5. OHSAS/OSHA certificate TOP COMPETITORS Name of Company 3. 4. 5. Page 13 of 16
BACKGROUD INFORMATION ON CHIEF EXECUTIVE OFFICER / OWNER / PARTNER Name Designation Highest Educational Attainment Educational Institution Appointed Date Degree Earned Year Graduated Nationality Age Years in Related Field Past Work Experience: Designation Company From To Other Directorships BACKGROUND INFORMATION ON CHIEF FINANCE OFFICER Name Designation Highest Educational Attainment Educational Institution Appointed Date Degree Earned Year Graduated Nationality Age Years in Related Field Past Work Experience: Designation Company From To Other Directorships BACKGROUND INFORMATION ON CHIEF OPERATING OFFICER Name Designation Highest Educational Attainment Educational Institution Appointed Date Degree Earned Year Graduated Nationality Age Years in Related Field Past Work Experience: Designation Company From To Other Directorships Page 14 of 16
KEY PERSONNEL OTHER THAN DIRECTORS Name Designation Employment Date SUPPLIER'S DECLARATION ON SAFETY, HEALTH, AND ENVIRONMENTAL POLICIES AND PRACTICES Yes ( ) No ( ) Does your company have an EMS certified to ISO 14001? Does your company have an OSH Management System certified to OHSAS 18001? 3. If NO to items 1 and 2, does your company have a policy on occupational safety, health and environment? 4. Does your company have an organization who manages the safety, health and environmental concerns of your company? 5. Have you identified the significant environmental aspects of your company? 6. Have you identified the occupational hazards and risks of the different activities in your operations? 7. Do you have programs in place to ensure your employees' safety and wellness? 8. Do you have programs in place to manage your environmental aspects? 9. Do you have programs in place to save on resources like energy and water? 10. Do you have a program to manage your Greenhouse Gas emissions? 1 Do you evaluate your own suppliers on their SHE policies and practices? 1 Please list the major laws and other legal requirements that your company comply with. a. b. c. Page 15 of 16
CONFLICT OF INTEREST DECLARATION Does your company have any direct/indirect business with Globe Telecom competitors (PLDT/Smart/Digitel/Liberty Telecom)? If yes, please indicate so: Nature of Business Globe Telecom Competitor Name # of Years Any Executives / Directors in your company with direct / indirect business with Globe Telecom? If yes, please indicate so: Vendor Executive / Director Name Position Nature of Business Any Executives / Directors in your company with direct / indirect business with Globe Telecom competitors (PLDT/Smart/Digitel/Liberty Telecom)? If yes, please indicate so: Vendor Executive / Director Name Position Nature of Business Any Executives / Directors in your company with relatives in Globe Telecom? If yes, please indicate so: Vendor Executive / Director Name Position Globe Telecom Employee Name Position OTHER RELEVANT INFORMATION Present service availed from Globe Telecom ( Fax Service/Handy phone/globe lines/leased service/g-net/others): Type of Plan Account No. Credit Limit 3. Any Officer / Employees / Agent of your company with relative in Globe Telecom? If yes, please indicate so: Vendor Employees / Agent Name Position Globe Telecom Employees / Agent Name Position I hereby certify that all information provided here in the Supplier Registration Form and in all supporting documents are true and correct. I hereby authorize Dun and Bradstreet Philippines, Inc. to verify any and all information furnished by me. In this connection, I hereby expressly waive any and all statutory or regulatory provisions governing confidentiality of such information if applicable. I fully understand that any misrepresentation of failure to disclose information as required herein may cause the disapproval of this application and removal from the list of accredited suppliers of Globe Telecom. Authorized Representative (Signature over Printed Name) Designation Date Page 16 of 16