**Announcement for Proposals, 2004-3**

**Joint Fire Science Program**

**[U.S. Department of the Interior]{.underline}**

**Bureau of Indian Affairs**

**Bureau of Land Management**

**National Park Service**

**U.S. Fish and Wildlife Service**

**U.S. Geological Survey**

**[U.S. Department of Agriculture]{.underline}**

**Forest Service**

**Opens October 15, 2003**

**Closes December 15, 2003**

**NOTE TO POTENTIAL PROPOSERS: There are significant changes in
requirements for proposals. Please read the AFP carefully.**

This Announcement for Proposals includes one Task Statement on ABest
Management Practices@

**Announcement for Proposals**

by the

Joint Fire Science Program

(Note: The Joint Fire Science Program previously posted Requests for
Proposals (RFPs). These are now called Announcements for Proposals
(AFPs).

**A. Program Description**

The Joint Fire Science Program (JFSP) is a partnership of six federal
wildland management and research agencies with a need to address
problems associated with managing accumulating wildland fuels
(combustible material, generally living and dead plant materials), fire
regimes, and fire-impacted ecosystems on lands administered by the
partner agencies. The partner agencies include the USDA Forest Service
and five bureaus in the Department of the Interior (Bureau of Indian
Affairs, Bureau of Land Management, National Park Service, U.S. Fish and
Wildlife Service, and the U.S. Geological Survey). For the purposes of
this Announcement for Proposals (AFP), \"wildlands\" are considered to
be forests, woodlands, shrublands, grasslands, and associated wetlands
and riparian areas.

Wildland fuels have been accumulating during at least the past
half-century due to wildland fire management policies, wildland
management practices, and other factors. As demonstrated in recent
wildland fires, the additional fuels contribute to intense fire behavior
and increase the resistance of fires to control. Consequently, property
and natural resources have been destroyed, costs of fire management have
escalated, fire dependent ecosystems have deteriorated, and the risks to
human life continue to escalate.

The Congress, agency administrators, JFSP partners, research scientists,
and others have recognized that the accumulation of wildland fuels must
be reduced in order to reduce the human threat from fire and maintain
natural resource values. Congress directed the Department of the
Interior and the USDA Forest Service to develop a Joint Fire Science
Plan to provide science-based support to land management agencies as
they address this need. The JFSP was established with the 1998
Appropriation for Interior and Related Agencies to help ensure that
cooperating Federal land management agencies expedite scientifically
sound, efficient, systematic, and effective solutions and monitoring
programs that cross agency jurisdictions and fuel types.

The 1998 Joint Fire Science Plan addressed four issues (Principal
Purposes) critical to the success of the fuels management and fire use
programs. These include wildland fuels inventory and mapping, evaluation
of fuels treatments, scheduling of fuels treatments, and monitoring and
evaluation. The Congress included additional direction in the 2001
Appropriation for Interior and Related Agencies. In addition to the four
original Principal Purposes, the JFSP was directed to focus attention on
such issues as protocols for evaluating post fire stabilization and
rehabilitation projects, aircraft based remote sensing, and
regional/local issues.

For further background on the goals of the JFSP, those considering
submitting proposals and other interested parties are encouraged to
review the Joint Fire Science Plan which is available via the Internet
at: http:jfsp.nifc.gov. In addition, the JFSP issued AFPs in June 1998,
February 1999, February 2000, February 2001, and October 2003 and
subsequently selected and funded more than 220 projects. Previous AFPs
and lists of funded projects can also be found on the JFSP web page.

This AFP contains one Task Statement for which proposals are sought. The
JFSP encourages proposals from all interested parties. However, because
the focus of the JFSP is on wildland fire and fuels issues on Federal
wildlands, evidence of direct involvement by Federal scientists or land
managers in the development of proposals must be included in all
proposals**. Proposals that do not have evidence of direct involvement
by federal land managers and/or scientists will not be considered for
funding.** Examples of documented involvement by land managers or
scientists include participation as a Principal Investigator,
cooperator, or collaborator; letters of commitment and support; and
written evidence from the manager that the proposal is responding to an
urgent fire or fuels issue involving or pertaining to the land manager=s
unit.

**All proposals must include the following items to be considered. The
JFSP program office must receive the complete proposal package
(including all items in the checklist below) by close of business (5:00
pm MST) December 15, 2003. There will be no exceptions to this closing
date; incomplete proposals will not be considered.**

**Facsimile or e-mailed proposals will no longer be accepted.**

1\) One original and five copies of complete proposal packet including
all material.

2\) An electronic version on a diskette or compact disk (in Word or
WordPerfect format) must be included.

3\) Signature of a principal investigator (PI), (this person will be the
technical contact for the JFSP office), Federal cooperator or land
manager (if different than the PI) as appropriate (see definitions of
Federal cooperator and land manager), and a concurrence signature of the
appropriate Federal Administrative or Contracting Officer.

4\) Complete address including phone number, mailing address, surface
mail address (if different than mail address) and e-mail address of
principal investigator, Federal cooperator or land manager as
appropriate, and appropriate Federal Administrative or Contracting
Officer.

5\) Letters of support are not required but are considered in the review
process. However, all letters of support that are submitted must be
included with the hard copy proposal package by the due date. Each
letter must clearly state the title of the project and the principal
investigator of the proposed work.

Questions and proposals should be directed to:

Dr. Bob Clark

Program Manager

Joint Fire Science Program

National Interagency Fire Center

3833 S. Development Ave.

Boise ID 83705

phone (208) 387-5349

e-mail: Bob_Clark@nifc.blm.gov

Proposed project budgets can be complex, often involving multiple
agencies or units in association with non-Federal units. Proposers
should ensure that appropriate Federal Administrative Officers,
Contracting Officers, or Grants and Agreements Specialists, as well as
budget or grants and contract offices of non-federal cooperators, review
the proposal prior to submission to ensure that the budget and other
fiscal aspects of the proposal meet agency requirements. The appropriate
AO/CO/Grants and Agreements Specialist concurrence signature from the
lead agency is required as identified in number 3 above.

**B. Area of Interest for Proposals**

This AFP contains one Task Statement:

**Task 1:** ***Pre-proposals are sought for projects to identify and
describe Best Management Practices (BMPs) (see Definitions, section F)
for fuels treatment methods specific to one or more major vegetation
types to assist hazardous fuels treatment project design,
implementation, analysis and review. Following evaluation and review of
pre-proposals submitted in response to this AFP, the JFSP intends to
request expanded proposals from selected submitters prior to final
evaluation and selection for funding.***

This task is in response to the Ten-year Implementation Plan of the
Comprehensive Strategy for the National Fire Plan which calls for the
development of BMPs specific to different ecosystems to facilitate
expedited review under NEPA, ESA, Clean Air Act and National Historic
Preservation Act.

Pre-proposals should include all of the information required by this
AFP. However, the text of the proposal should not exceed eight pages.

The proposed deliverables should build on existing information on fire
regime classification, autecological effects of fire, fire regime
characteristics and post-fire plant community developments in ecosystems
contained in existing publications, such as [Wildland Fire in
Ecosystems: Effects of Fire on Flora]{.underline}. (Brown, James K., and
Jane Kapler Smith (eds). 2000. Gen.Tech. Rep. RMRS-GTR-42-vol. 2).
Proposals are requested to develop BMPs for one of the following major
vegetation types (as classified in Brown and Kapler Smith) where the
majority of National Fire Plan fuel treatments are planned for near
future.

Ecosystems for which pre-proposals are sought:

Western Forest Ecosystems

 Ponderosa Pine

 Ponderosa Pine/Jeffrey Pine and Ponderosa Pine-Mixed Conifer

 Interior Douglas-fir, Larch

 Rocky Mountain Lodgepole Pine

Western Shrubland, Woodland and Grassland Ecosystems

 Chaparral B Mountain Shrub

 Southwestern Ponderosa Pine

 Pinyon-Juniper

 Sagebrush

Eastern Ecosystems

 Loblolly Pine

 Mixed Mesophytic Forest

Northern Ecosystems

 Black Spruce/Jack Pine/Red Pine

Tropical and Sub-tropical Ecosystems

 Pine Flatwoods and Pine Rocklands

The deliverables should be designed to aid the development of
operational management projects. Products should assist land managers in
their efforts to plan and evaluate fuels treatment projects and support
them in the selection of appropriate fuels treatment methods, fire use,
and associated practices at stand to landscape scales.

The JFSP Governing Board intends that projects funded under this task
will be coordinated with each other to ensure consistency and
compatibility, and to enhance their usefulness in planning and
decision-making. The final outputs are envisioned as a series of
synthesis products that will provide a description and analysis of
current knowledge and decision support tools, discuss implications of
alternative management strategies, and make recommendations of
management practices appropriate to achieving a variety of outcomes. The
techniques utilized will vary depending on the information and
literature currently available. Each project team must include at least
one land manager familiar with program implementation issues and
challenges of hazardous fuels projects in the subject vegetation type.

Topics addressed should, at a minimum, include treatment methods
including mechanical, biological, fire, and chemical treatments at the
local to landscape scale; economics; markets and non-market conditions;
product value; and other considerations for conducting fuels treatments
in an ecosystem context. Best Management Practices should be
differentiated relative to the values to be protected including Wildland
Urban Interface; Threatened, Endangered and Sensitive habitat;
watersheds; air quality; and the Wildland/Urban Interface.

One or two proposers from each selected project will be required to
participate in a kickoff workshop to discuss goals, identify common
standards and format for deliverables, develop a timeline for work, and
develop an overall study plan and final budget proposal for
accomplishing the work of the teams. The workshop costs will be borne by
the Joint Fire Science Program. A Steering Committee comprised of one PI
from each selected project team and a representative of the Joint Fire
Science Program will oversee the implementation of the plan of work.
Proposers will be given an opportunity to make minor adjustments their
proposed budget as the study plan is developed. These proposed final
budgets will be reviewed by JFSP and approved after negotiating any
necessary revisions.

Projects will be funded for a maximum of 18 months from the award date.
The technology transfer plan must clearly describe methods for rapid
dissemination of results to managers and practitioners. Contingent on
the availability of funding, the Board may reissue this AFP on an annual
basis until the major vegetation types have been addressed.

Best Management Practices syntheses will be subjected to a peer review
process prior to completion. This process will be conducted by the JFSP
Program Office.

**C. Format for Proposals**

**Overview of the Proposal Format**

The pre-proposal should specify rationale, objectives, methodologies,
and deliverables in sufficient detail to allow an informed reader to
assess the proposal\'s validity in addressing the Task Statement in this
AFP. The pre-proposal text and accompanying tables and figures,
exclusive of curricula vitae or other appended information, should be
limited to eight pages. Please use at least 11-point font. Annual and
total (18 month) budgets and a timeline for deliverables must be
included, as well as a mechanism for technology transfer to appropriate
end users. The proposal also provides a record of management
responsibility and accountability for various aspects of the project.

**Title Page**

The following format should be used for the title page (not to exceed 1
page):

+-----------------------------------------------------------------------+
| Project Title:                                                        |
|                                                                       |
| Announcement for Proposals this proposal is responding to:            |
|                                                                       |
| Principal Investigator(s):                                            |
|                                                                       |
| Affiliation:                                                          |
|                                                                       |
| Address:                                                              |
|                                                                       |
| Telephone/Facsimile Number(s):                                        |
|                                                                       |
| E-mail:                                                               |
|                                                                       |
| Federal Cooperator (please include full mail and e-mail addresses as  |
| well as phone number:                                                 |
|                                                                       |
| Duration of Project:                                                  |
|                                                                       |
| Annual Funding Requested from the Joint Fire Science Program: \$      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_                                          |
|                                                                       |
| Total Funding Requested from the Joint Fire Science Program: \$       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                        |
|                                                                       |
| ***Total Value of In-Kind and Financial Contributions: \$             |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***                         |
|                                                                       |
| Abstract: Summarize the proposed project in a brief abstract not to   |
| exceed 2 page. The abstract should include the justification for the  |
| proposed project in relation to one or more task statements in the    |
| AFP, objectives, appropriate methodology, and applicability of        |
| results.                                                              |
|                                                                       |
| Signature of PI                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Date:                                                                 |
|                                                                       |
| Signature of Federal Cooperator:                                      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:    |
|                                                                       |
| Concurrence of Federal Cooperator fiscal                              |
| representative:\_\_\_\_\_\_\_\_\_\_\_\_ Date:                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

**Introduction**

An introductory section should include:

1\) Project Justification. A brief summary describing why this project
needs to be completed in this ecosystem and benefits derived.

2\) Project Objectives. A statement of the project objective(s) must be
clearly stated. This should include a brief statement of the information
or product(s) that will be provided at the end of the project, and how
the information or product can be used to resolve the issue(s) stated in
the task statement.

3\) Background. This section includes a concise review and synthesis of
existing knowledge and previous research or other pertinent background
information, a description of how the proposed project adds to or
improves existing knowledge or tools, and a description of coordination
with other relevant ongoing or completed products to ensure
cross-compatibility and eliminate redundancy.

The introductory section is intended to provide peer reviewers and the
Governing Board with evidence that the proposed work compliments
previous and on-going work and that the work is applicable to Task
Statement in the AFP. Although the literature may be extensive, the
synthesis should generally include reference to no more than about 12-15
of the most important and/or most relevant sources.

**Materials and Methods**

This section should describe procedures proposed for conducting the
project in sufficient detail that a knowledgeable reviewer could
understand the process.

**Project Duration**

The Governing Board anticipates that all projects funded from this AFP
will be completed within 18 months.

**Budget**

The proposed budget should be provided in sufficient detail to identify
direct and indirect costs and related surcharges, to separate labor
costs from operational costs, and to identify salaries associated with
funded scientists. Contributed costs and the source of those costs
should be included in the budget, and annual and total costs should be
provided. Separate line items for \"capitalized\" equipment (more than
\$5000) should be included. Outyear projections should be included for
multi-year proposals. Proposed budgets should include travel expenses
for one PI to participate in an annual 3-day PI workshop. The Governing
Board of the Joint Fire Science Program reserves the right to negotiate
budget amounts and deliverables with proposing organizations. The JFSP
standard indirect rate is 20% for agencies/units/institutions conducting
the work, and 10% administrative on funds passed through to
collaborators. See section on Indirect Costs below.

**Deliverables**

Proposals must provide specific details on the information or product(s)
that would be provided by the proposed work, and a realistic timetable
for delivery. It is expected that all final products will include an
electronic version suitable for distribution, posting, etc. Descriptions
in English units, with metric equivalents in parenthesis, are required.
Annual progress summaries are required.

**Science Application and Delivery (formerly Atechnology transfer@)**

It is imperative that deliverables reach end users. Therefore, each
proposal should include a description of how the BMP syntheses would be
distributed to the field.

**Qualifications of Investigators**

Include Curriculum Vitae for primary PI(s) and at least one Federal
cooperator, land manager, or research collaborator. These should reflect
recent, relevant experience and publication(s) and should not exceed 2
pages.

**D. Review and Evaluation of Proposals**

**Facsimile or e-mailed proposals will no longer be accepted.**

**Checklist of items that must be included in Proposal Submissions**

G One original and five copies of complete proposal packet including all
material,

G An electronic version on a diskette or compact disk (in Word or
WordPerfect format) must be submitted with the packet.

G Signatures of principal investigator (PI), (this person will be the
technical contact for the JFSP office), the Federal cooperator or land
manager (if different than the PI) as appropriate (see definitions of
Federal cooperator and land manager), and signature of concurrence of
the appropriate Federal Administrative or Contracting Officer.

G Complete address including phone number, mailing address, surface mail
address (if different than mail address) and e-mail address of the
principal investigator, Federal cooperator or land manager as
appropriate, and Federal Administrative or Contracting Officer who would
administer the fiscal aspects of the project.

G Letters of support are considered in the review process but are not
required. However, letters of support that are submitted must be
included with the proposal package. Letters must include the title and
principal investigator of the project.

G An introduction or background section that includes the specific
objectives of the project and describes how the proposed work is
relevant to Task Statement in the AFP.

G A list of cooperators and their proposed contribution.

G A Curriculum Vitae or other description of credentials of the PI and
co-investigator(s) that are signatories which demonstrates ability to
complete the proposed work

G A brief review and synthesis of related past and current literature
and work

G A first year and total budget, including identification of salaries
and indirect costs.

G Include a AJustification of Need for Salary Support,@ approved by
appropriate authority, as necessary.

G A list of deliverables with proposed dates of delivery

G A science delivery and application mechanism.

G Letters of support.

**Review and evaluation:**

Reviews and evaluations of proposals submitted in response to this AFP
to the Joint Fire Science Program will focus on the following five
factors:

 Relevancy

 Scientific Methods and Study Design

 Products and Delivery into Application

 Collaboration and Leverage

 Administrative Adequacy

Criteria associated with the factors include:

Relevancy:

1\. Does the proposal address the Task Statement in the AFP?

2\. How relevant is the proposed work to field level personnel?

3\. Does the Project Justification adequately describe why the project
needs to be done?

4\. Is there evidence that land managers need the proposed work?

5\. Does this proposal demonstrate new or significant contributions to
existing knowledge bases?

Scientific Methods and Study Design:

1\. Are study approaches appropriate and adequate to meet stated
objectives?

2\. What are the qualifications of the team to do the proposed work? Are
adequate institutional resources and support available?

3\. If the proposal involves software development, does it include
beta-testing in the proposal and is there evidence that the proposal
addressed agency system architecture and security requirements?

Products and Delivery into Application

1\. Does the proposal provide for adequate transfer of information or
products and consider general availability and usefulness of proposed
technology?

2\. Is the proposed work cost effective?

3\. At what scale will the proposed work provide information or
products? Are the products useful across agency jurisdictions, fuel
types, and geographic areas?

4\. Does the delivery method facilitate or enhance the utility of the
scientific information for management application?

5\. Does the delivery use an combination of passive and active science
application and delivery methods?

Collaboration - Leverage:

1\. How well does the proposed work build on or interface with past or
ongoing studies or products on related topics?

2\. Does the proposal provide for adequate collaboration among agencies,
between fire and land management personnel and research scientists or
other collaborators, and between disciplines to ensure broad integration
of existing knowledge and approaches as well as applicability of results
and recommendations?

3\. Is there evidence of local or regional agency support and
involvement in the proposal?

Administrative Adequacy:

1\. Does the proposal follow the requested format and include all the
requested information?

2\. If formal cooperative arrangements are proposed (e.g., with
universities or other non-federal organizations), is there documentation
that these will be feasible and agreeable to the cooperators?

3\. Does the proposal address compliance with the National Environmental
Policy Act, Threatened/Endangered Species Act, or similar statues?

4\. Are proposed timeframes and budget reasonable and adequately
justified, including budgets for proposed sub-agreements?

5\. Are the in-kind contributions reasonable/adequate with the proposed
budget?

6\. Is a justification for salaries included and adequate?

**E. Indirect Costs and Salary Policy**

**Indirect Costs**

The JFSP Governing Board recognizes the need of participating
organizations to recover reasonable indirect costs. At the same time,
the JFSP has limited authority to pay indirect costs, and cost is
clearly a factor in the final proposal selection process. The JFSP
maximum allowed indirect rates are 20 percent for that portion of the
funding that is used by units/institutions conducting the work, and 10
percent administrative cost to the Federal cooperator for Apassing
through@ funding to those cooperating units/institutions.

**Salary Policy**

Normally, salaries of permanent full-time Federal employees are expected
to be provided by their agencies. This is also true of university
faculty on 12-month tenure-track appointments. These employees are
already fully funded by their organizations or institutions. However,
the Governing Board recognizes that there can be mitigating
circumstances arising from the need to fill in behind these employees
when they are reassigned to Joint Fire Science Program funded
activities, or due to policies of individual organizations. In such
cases, the Governing Board may agree to fund salaries of permanent
employees. A brief justification must be included in the proposal, and
the justification must be certified by an appropriate institutional
authority, other than the PI or other cooperator on the proposal, at the
employee=s organization or institution. The format provided below should
be used for the certification. In addition, permanent employee salary
costs must be explicitly identified in the proposed budget. The
Governing Board requires no special justification (other than a brief
description of the need for the position in the budget justification
section of the proposal) for funding temporary or term employees,
post-doctoral employees, or graduate or undergraduate students. Stipends
are normally funded but tuition is not.

**F. Definitions**

**Agency Administrator:** The agency Administrator is the official
responsible for administering policy on an area of public land who has
full authority for making decisions and providing direction. Also known
as \"Agency Line Officer,@ ALine Officer,@ and ALand Manager.@ Examples
include Park Superintendent, Forest Supervisor, District Manager, Refuge
Manager, District Ranger, and Field Office Manager. Research line
officers are not included for the purpose of this AFP.

**Announcement for Proposals (or AFP):** Joint Fire Science Program
method of requesting proposals. AFPs include Task Statements for which
proposals are sought, instructions for proposal submission, and related
information.

**Best Management Practices (BMPs):** Proactive practical methods or
practices used during land management activities, such as fuel
treatments, to achieve goals related to water quality, air quality,
silviculture, wildlife habitat, biological diversity, aesthetics,
recreation, and similar factors.

**Federal Administrative or Contracting Officer**: The individual
attached to the Federal proposer=s or Federal cooperator=s unit who will
be responsible for the administrative and fiscal aspects of the proposed
work. This individual is typically an Administrative Officer,
Contracting Officer, or Grants and Agreements Specialist.

**Federal Cooperator:** Representative of a Joint Fire Science Program
partner agency.

**Indirect Costs:** Those costs that are not directly attributable to a
specific research project. Examples include the cost of operations and
maintenance such as janitorial, phone, and clerical services. The Joint
Fire Science Program recognizes two types of indirect costs: Ain-house@
costs incurred by the agency, institution, or unit completing the
research, and Apass-through@ costs associated with passing funds to
another agency, institution, or unit for the purpose of completing
research. Indirect costs are limited to 20 percent of that portion of
the proposed budget attributable to the agency, university or unit that
is completing the research. Pass-through administrative costs are
limited to 10 percent of the funds that are forwarded to the agency,
university, or unit that is completing the research. Equipment purchased
(\$5000 or more) to support the research project are excluded from
indirect costs.

**Joint Fire Science Program Governing Board:** An appointed, 10-person
board, representing the JFSP partners, that manages the JFSP. The Board
drafts and posts Announcements for Proposals, selects proposals for
funding, supervises the JFSP Manager and program office, and conducts
related business.

**Joint Fire Science Program PI Workshop:** Annual workshop, typically
in the Spring, in which PIs of JFSP-funded projects provide progress
reports, discuss research-related issues, and conduct other business.

**Land Manager:** see Agency Administrator

**Principal Investigator (or PI):** The individual identified in a
proposal who is primarily responsible for completing a research project.
This person will be the main technical contact for the JFSP Office.

**Problem Statement or Statement of Need:** A brief statement, written
and signed by the agency administrator, which clearly describes the need
for the proposed work and how the proposed work would resolve the issue.
The statement also includes the agency administrator=s commitment to
supporting the proposed work. The problem statement is typically one
page or less.

**Science Delivery and Application (formerly Atechnology transfer\"):**
The transfer of information, materials, models and other research
deliverables to end users, along with adequate information to user or
apply the deliverables. Examples of active methods include workshops,
training sessions, guided field tours, conferences, meetings, and
symposia. Examples of passive methods include published papers and
websites. A combination of active and passive methods is preferred.

**Task Statement:** A specific area of interest, identified in an
Announcement for Proposals, for which proposals are sought.

**Certification to the Joint Fire Science Program**

**Justification of Need for Salary Support**

I hereby certify the attached Justification of Need to provide temporary
salaries for full-time permanent employee
(s)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*(list name of
employee(s))* is necessary and appropriate to enable him/her (them) to
fully and directly participate in the proposed project.

Justification:

I understand that salary funding for this/these employee(s) directly
involved in the proposed project is temporary and will not be provided
beyond the duration of the proposed project.

Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (type or print)

Title
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Phone Number