Jing Si Herbal Tea in the Treatment of Dyspeptic Symptoms and Psychophysical Burden in Patients With Functional dyspepsia--a Double-blind, Randomized, Placebo-controlled Study
Phase: NA
Conditions: Functional Gastrointestinal Disorders, Healthy Subjects
Sponsor: Buddhist Tzu Chi General Hospital

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 1 
Only with the stamp of this 
committee will it be valid 
 
 
Revised version of Research Ethics Committee meeting 23 February 2021 
Project name 
English：Jing Si Herbal Tea in the treatment of dyspeptic symptoms and psychophysical burden 
in patients with functional dyspepsia--a double-blind, randomized, placebo-controlled 
study 
Test agency: 
Buddhist Tzu Chi Medical Foundation 
Hualien Tzu Chi Hospital 
Gastroenterology 
Entrusting unit/pharmaceutical factory: None 
Research funding source: Hualien Tzu Chi Hospital 
Trial Host: Dr. Chen, Chien-Lin Unit/ Title: Division of Gastroenterology / Director 
Co-host: Dr. Wong, Ming-Wun Unit / Title: Division of Gastroenterology / Attending Physician 
Co-host: Dr. Yi, Chih-Hsun Unit / Title: Division of Gastroenterology / Attending Physician 
Co-host: Dr. Liu, Tso-Tsai Unit/ Title: Gastrointestinal Examination Room/Director 
Co-host: Dr. Lei, Wei-Yi Unit/ Title: Division of Gastroenterology / Attending Physician 
Co-host: Dr. Hung, Jui-Sheng Unit / Title: Division of Gastroenterology / Attending Physician 
Co-host: Dr. Liang, Shu-Wei Unit / Title: Integrative Medicine/ Resident Physician 
Co-host: Liu, Chin-Hung Unit / Title: Department of Pharmacology, College of Medicine, Tzu 
Chi University / Associate professor 
24-hour emergency contact person: Dr. Chen, Chien-Lin Tel: 0988-282055 
Subject name:                        Medical record number: 
Before your questions are answered satisfactorily , please do not sign this consent form. 
You do not have to decide immediately whether to participate in this trial, please sign 
after careful consideration. You must sign a consent form to participate in this trial. If you 
wish to participate in this trial, this document will be considered a record of your consent. 
Even with your consent, you can withdraw from the trial at any time without giving any 
reason. 
A. Purpose of the test : 
This trial is a clinical trial in a single center in Taiwan, and it is expected to enroll 300 
people. This test is a double-blind randomized test, the purpose of which is to investigate the 
improvement degree of Jing Si Herbal Tea on the physical and mental symptoms of functional 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 2 
dyspepsia (FD) . Functional dyspepsia (FD) is a common disease, but the effect of traditional 
western medicine is worthy of improvement. Jing Si Herbal Tea is a Chinese herbal food 
developed locally. This study adopts a double-blind randomized trial. Jing Si Herbal Tea is 
normal in the objective examination For patients with functional dyspepsia, evaluate their 
physical and mental symptoms before and after treatment, as well as changes in intestinal 
bacterial metabolites. 
Any treatment has risks, and clinical trials are no exception. Please consider 
carefully before deciding whether to participate in this trial. 
B. 
Research background or product status : 
Jing Si Herbal Tea 
The ingredients of Jing si Herbal Tea are eight kinds of Chinese herbal medicines in 
Taiwan, such as Artemisia argyi, Houttuynia cordata, Ophiopogon japonicus, Houttuynia 
cordata, Platycodon grandiflorum, Licorice root, Perilla leaf, Chrysanthemum, etc. , the current 
study found that it can block the combination of the new coronavirus and the cell, and can also 
reduce the cell penetration, and block the virus from penetrating the cell, and the wild type and 
the mutant virus D614G, B.1.1.7, 501Y.V2 were tested in animals Studies have found that Jing 
Si Herbal Tea can reduce the ability of 60-70% of the virus to infect the upper respiratory tract, 
lungs, heart, and intestines of mice and reduce the expression of the protein FKBP51 related to 
depression by 40%. Currently, clinical trials have been registered (ClinicalTrials.gov Identifier : 
NCT04967755) for COVID-19 patients using Jing Si Herbal Tea to help reduce the amount of 
virus. 
C. 
The main inclusion and exclusion conditions of the trial: 
     Physicians or related researchers who carry out this research project will discuss with 
you the necessary conditions for participating in this research. Please cooperate and honestly 
tell us your past health conditions. If you are not eligible to participate in this study, you will 
not be able to participate in this study. 
1. 
Inclusion conditions (conditions for participating in this study): 
(1) Age limit 20 to 79 years old. 
(2) Those who meet the definition of chronic dyspepsia (FD). 
(Functional dyspepsia (FD) is chronic ( once a week , lasting for at least three 
months, at least six months before the first symptom) upper gastrointestinal 
symptoms (any of the following ) : abdominal distension after meals, easy to feel 
full , epigastric pain or burning sensation in the upper abdomen, and no 
symptoms of gastrointestinal bleeding or significant weight loss, and no 
abnormality after upper gastrointestinal endoscopy.) 
(3) Clear consciousness and willing to sign the subject's consent form. 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 3 
2. 
Exclusions (if you have any of the following conditions , you will not be able to 
participate in this study): 
(1) Abnormal liver and kidney function; 
(2) Abnormal blood test, abnormal thyroid gland; 
(3) Have undergone esophageal or gastric surgery; 
(4) Abnormal upper gastrointestinal endoscopy; 
(5) Have gastric pylori infection; 
(6) Antibiotics are being used for infectious diseases; 
(7) Pregnant or breastfeeding women; 
(8) Suffer from heart, liver, kidney failure. 
(9) Weakness, allergies, coldness , chronic diseases, poor kidney function, infants 
under three years old, children, pregnancy, breastfeeding, menstrual period. 
D. The test method and related procedures: 
This study is a prospective study, which is expected to last for 1 year. It is planned to recruit 
300 functional dyspepsia (FD) subjects from the Department of Gastroenterology and 
Hepatobiliary Medicine. Functional dyspepsia (FD) is chronic ( once a week , lasting for at least 
three months, at least six months before the first symptom) upper gastrointestinal symptoms 
(any of the following ) : postprandial abdominal distension, easy to feel full, If you have 
epigastric pain or burning sensation in the upper abdomen, and have no symptoms of 
gastrointestinal bleeding or significant weight loss, and there is no abnormality in upper 
gastrointestinal endoscopy, if you meet the definition of chronic dyspepsia (FD), you decide to 
join this study and sign this After the consent form, eligible subjects received blood tests and 
complete physical and mental symptom assessments (PSQI, TDQ, PSS-10, STAI, PAGI-SYM) 
before treatment, and then randomized according to double - blind The method is to generate 
garbled codes by computer, and 150 of them are included in the Jing Si Herbal Tea group , and 
the other 150 are included in the placebo group according to the coding sequence. After 
grouping, the research assistant gave Jing Si Herbal Tea or placebo, and neither the host nor the 
subjects knew which group to assign. The period of taking Jing Si Herbal Tea or placebo lasted 
for a total of two months. At the end of the first month, blood test (LC-MS pre- and post-test 
analysis) and complete physical and mental symptom assessment (PSQI, TDQ, PSS-10, STAI, 
PAGI-SYM) were accepted again. In the next month, the Jing Si Herbal Tea group and the 
placebo group were cross-tested. The original placebo group was changed to Jing Si Herbal Tea, 
and the Jing Si Herbal Tea group was changed to placebo. At the end of the course of treatment, 
the third complete physical and mental symptom assessment was accepted. (PSQI, TDQ, PSS-
10, STAI, PAGI-SYM). 
 
Research Program Map: 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 4 
 
Jing Si Herbal Tea 
In this experiment , Jing Si Herbal Tea Concentrated Liquid is used. Its ingredients are eight 
kinds of Taiwanese local ingredients, such as mugwort leaves , houttuynia cordata, 
Ophiopogon japonicus, Houttuynia cordata, Bellflower, licorice, perilla leaves, and 
chrysanthemum. , Dampness-clearing and heat-clearing Chinese herbal medicine, take 15 ml 
of Jing Si Herbal Tea concentrate once a day . 
E. 
Possible risks and their incidence and treatment methods: 
※Jing Si Herbal Tea and placebo are suitable for ordinary people; people with infirmity, 
allergies, coldness , chronic diseases, poor kidney function, infants under three years old, 
children, pregnancy, breastfeeding, and menstrual period, please use with caution; if you feel 
unwell, please stop using. Do not drink before going to bed to avoid frequent urination at night 
and affect sleep. 
If you feel uncomfortable physically and mentally due to the long time of filling out the 
questionnaire, please inform the research host or other researchers at any time. If you want to 
withdraw from this study, we will respect your wishes. 
   You will be monitored regularly for side effects while you are in the trial by the trial 
physician and other trial staff. Additional visits and tests will be scheduled as necessary. If you 
have side effects, please inform the trial physician and other trial personnel, and the trial 
physician will decide to give appropriate treatment according to your situation. 
  If you have any of these serious or dangerous side effects you should as soon as possible: 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 5 
1. Call the 24-hour emergency contact. 
2. Go to the nearest emergency room if necessary. 
F. 
Other Alternative Remedies & Instructions: 
You are not obliged to participate in the study. If you do not participate in the study, the doctor 
will check your symptoms through routine examination and give appropriate drug treatment. 
G. Expected benefits of the trial: 
At present , Jing Si Herbal Tea has been observed in animal experiments to block the 
combination of the new coronavirus and cells, and can also reduce cell penetration and block 
the virus from penetrating cells. 501Y.V2 conducted animal research and found that Jing Si 
Herbal Tea can reduce the ability of the upper respiratory tract, lungs, heart, and intestines of 
mice infected with the virus by 60-70% and reduce the expression of FKBP51, a protein 
related to depression, by 40%. Clinical trials have been registered (ClinicalTrials.gov 
Identifier: NCT04967755) The effect of using Jing Si Herbal Tea to help reduce the amount 
of virus in patients with COVID-19. In this study, Jing Si Herbal Tea was used to drink 
functional dyspepsia patients with normal objective examinations, and the changes of their 
physical and mental symptoms and intestinal bacterial metabolites were evaluated before and 
after treatment. 
Even with the above information, there is still no guarantee that participating in this trial will 
improve your condition or bring you other direct benefits, but the results of the trial may be 
helpful to the entrusting unit and/or the trial host, and will also be used in the future. May 
benefit other patients with the same disease. 
H. Contraindications, restrictions and matters that should be cooperated by the 
subjects during the trial: 
When you participate in this test , for your safety, please cooperate with the following 
-Provide your past medical history, medical records and correct information about your current 
condition. 
- Use Jing Si Herbal Tea correctly according to the instructions . 
-Do not give Jing Si Herbal Tea to others. Please keep Jing Si Herbal Tea (storage method: 
room temperature, refrigerated, etc.) and make sure it is out of reach of children. 
- For your safety, please inform the trial physician of any uncomfortable symptoms you 
experience. 
- If you have any questions, please feel free to ask the test personnel (physician, nurse) 
directly. 
- If you have been hospitalized or your medical condition has changed between two visits, or if 
you want to stop using Jing Si Herbal Tea (or have already stopped using it), please notify the 
trial physician. 
I. 
Confidentiality of personal data of subjects: 
Hualien Tzu Chi Hospital will treat any identifiable records and personal privacy information as 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 6 
confidential according to law and will not make them public. The researchers will identify you 
with a research code, which will not reveal your name, national ID number, address and other 
identifiable information. If the trial results are published, your identity will remain confidential. 
You also understand that if you sign the consent form, you agree that your original medical 
records can be directly reviewed by monitors, auditors, Hualien Tzu Chi Hospital Research 
Ethics Committee and competent authorities to ensure that the clinical trial process and data 
comply with relevant laws and regulations. personnel and undertake not to violate the 
confidentiality of your identity. In addition to the above-mentioned agencies having the right to 
review according to law, we will carefully safeguard your privacy. 
J. 
Withdrawal and suspension of the test: 
You are free to decide whether to participate in this trial; you can withdraw or suspend 
your consent at any time during the trial, and you can withdraw from the trial without any reason, 
and it will not cause any discomfort or affect the medical care of your doctor in the future. 
When there is important new information during the execution of the trial (referring to 
your rights or affecting your willingness to continue participating), you will be notified and 
further explained. Please reconsider whether to continue participating. You can decide freely 
and will not cause any discomfort. Or affect their future physicians to your medical care. 
The program director may also suspend the entire experiment if necessary. 
K. Damage Compensation and Insurance: 
Trials are bound to be risky. In order to ensure the possible protection for your damage due to 
adverse reactions during participation in the trial, please be sure to read this description 
carefully: 
1. Hualien Tzu Chi Hospital shall be responsible for compensation for damages caused by 
adverse reactions in accordance with the clinical trial plan formulated by this study . 
However, the expected adverse reactions recorded in the subject's consent form will not be 
compensated. 
2. If adverse reactions or damages occur due to the clinical trial plan formulated in this study, 
the hospital is willing to provide professional medical care and medical consultation. You 
do not have to pay for medically necessary treatment of adverse reactions or damages. 
3. Except for the first two items of compensation and medical care, this research does not 
provide other forms of compensation. If you are unwilling to accept the risk, do not take 
part in the trial. 
4. You will not lose any legal rights by signing this agreement. 
5. Liability insurance for human trials was not insured for this study . 
6. The test food has been insured for product insurance. (The insured is Dajiang Biomedical 
Co., Ltd.; policy number: 150110CG01568 ; product name: Jing Si Herbal Tea, Jing si 
Herbal Dettol . ) 
If you do suffer damage caused by adverse reactions due to your participation in this trial, the 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 7 
aforementioned compensation includes reasonable medical expenses, but the following 
conditions should be met: you use the trial drug according to the instructions of the trial doctor; 
your damage is not caused intentionally; you obey the trial doctor medical advice. 
L. 
Preservation, use and reuse of subjects' samples (including their derivatives) 
and personal data 
1. Specimen (including its derivatives), preservation and use of personal data 
   The specimens and related materials you provided will be used in this test plan and stored 
in the laboratory of Professor Liu,Chin-Hung , Department of Pharmacology, Faculty of 
Medicine, Hualien Tzu Chi University until December 31, 2024. When the storage period 
expires, they will be destroyed according to law. In order to protect your personal privacy, we 
will replace your name and related personal information with a test number to confirm that 
your specimen and related information are kept completely confidential. 
If you have doubts about the use of specimens and related materials, or have any need to destroy 
specimens or data, please contact us immediately (Contact Person: Dr. Chen, Chien-Lin; Tel: 
0988-282055; Contact Unit: Gastrointestinal Examination Room ; Tel: 03-8561825 ext. 13224; 
Address: No. 707, Section 3, Zhongyang Road, Hualien City ) , and we will destroy your 
specimen and related information. You can also contact the Research Ethics Committee of 
Hualien Tzu Chi Hospital (Tel: 03-8561825 ext. 12124) to assist you in resolving any disputes 
over the use of specimens and personal data in research. 
2. Storage and reuse of remaining specimens 
   This test does not save the remaining samples for reuse, and your samples will be 
destroyed after the storage period expires. 
3. Storage and use of personal data 
The personal information and related information you provide will be used in this trial 
project and stored in the gastrointestinal examination room of Hualien Tzu Chi Hospital 
until December 31, 2024. When the storage period expires, it will be destroyed according 
to law. In order to protect your personal privacy, we will replace your name and related 
personal information with a test number to confirm that your relevant information is kept 
completely confidential. 
If you have doubts about the use of relevant materials, or have any need to destroy the data, 
please contact us immediately (Contact Person: Dr. Chen, Chien-Lin; Tel: 0988-282055; 
Contact Unit: Gastrointestinal Examination Room; Tel: 03-8561825 Ext. 13224; address: No. 
707, Section 3, Zhongyang Road, Hualien City ) , and we will destroy your relevant information. 
You can also contact the Research Ethics Committee of Hualien Tzu Chi Hospital (Tel: 03-
8561825 ext. 12124) to assist you in resolving any disputes over the use of personal data in 
research. 
M. Subject rights: 
1. 
If you have doubts about the nature of the trial work during the trial, have opinions on 
the rights and interests of patients, or suspect that you have been victimized by 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 8 
participating in the research, you can contact the Research Ethics Committee of Hualien 
Tzu Chi Hospital for consultation. Tel: 03-8561825 ext. 12124 . 
2. 
During the trial, any major findings related to your health or disease that may affect 
your willingness to continue to accept the clinical trial will be provided to you 
immediately. If you decide to withdraw, your physician will arrange for you to continue 
receiving medical care. If you decide to continue in the trial, you may be required to 
sign an updated consent form. 
3. 
In order to carry out the experimental work, you must be under the care of Dr. Chen, 
Chien-Lin. If you have any questions or conditions now or during the trial, please feel 
free to contact Dr. Chen, Chien-Lin from the Gastroenterology Department of Hualien 
Tzu Chi Hospital ( 24-hour contact number: 0988-282055 ) . 
4. 
This consent form is in duplicate, and the trial host or his authorized personnel has 
given you a copy of the consent form , and has fully explained the nature and purpose 
of this research. Physicians have answered your questions about drugs and research. 
5. 
The subsidy for participating in the experimental research plan, in order to compensate 
you for the transportation and time spent on participating in the experiment, you will 
receive a subsidy of NT$300 after signing the agreement, and a subsidy of NT$300 after 
the experiment is completed, a total subsidy of NT$600. 
6. 
If after the trial is over, there are unexpected safety concerns that directly affect you, 
you will also be notified. 
N. The commercial benefits that may be derived from this research are 
expected: 
Information obtained from this trial may lead to the discovery, invention, or development of 
commercial products, and all such rights belong to the commissioner. You and your family 
will not receive any financial benefit or monetary compensation for the research and 
development results, inventions or other discoveries in this information, or have the ownership 
of the results of the above inventions. 
O. Instructions for signing the consent form: 
1. 
The consent form should be signed and dated after the research director or his 
authorized personnel explain the research content to the research subjects and 
answer all the questions of the research subjects; then ask the research subjects or 
their related persons to sign after consideration. 
2. 
Timing of signing by legal representative/person with consent/guardian/assistant: 
＊ Article 79 of the Medical Act/Article 12 of the Human Research Act/Article 5 of Good 
Clinical Practice Guidelines for Drugs/Article 6 of Precautions for Collection of Human 
Specimens for Research/Articles 13 and 15 of the Civil Code: 
(1) Subjects who are incapacitated (minors under the age of seven or persons declared 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 9 
under guardianship) shall be acted by their legal representatives; persons under 
guardianship declaration shall have their guardians act as their legal representatives. 
(2) The subject is a person with limited behavioral capacity (a minor over the age of seven, 
or due to a mental disorder or other mental defect, the ability to express or accept the 
expression of intention, or to recognize the effect of the expression of intention is 
obviously insufficient, and Those who have been assisted by the court) shall obtain the 
consent of the person himself and his legal representative or assistant. 
(3) Although the subject is not incapacitated or limited in capacity, but is unable to 
communicate and judge effectively due to confusion or mental and intellectual 
impairment, a person with the right to consent shall do so. The person with the right to 
consent is the spouse and relatives living together. 
(4) When the research object is a fetus, the consent of the mother should be obtained. 
(5) The provision of autopsy should be subject to the written consent of the person's closest 
relative or the person himself before his death. 
3. 
Witness signing timing: 
＊ Article 21 of the Good Clinical Practice Guidelines for Pharmaceuticals / Article 3 of the 
Civil Code: 
(1) When the subject, legal representative, or consenting person cannot read it, witnesses 
should be present to participate in all discussions about the subject's consent form. 
Witnesses should read the consent form of the subject and provide any other written 
information of the subject to witness that the research director or the person designated 
by him or her has accurately delivered the content to the subject, legal representative or 
person with consent explain, and make sure they fully understand the content of all 
materials. 
(2) The subject, legal representative or person with the right to consent shall still sign and 
date the subject's consent form. However, fingerprints can be used instead of signatures. 
(3) After the witness completes the oral statement and confirms that the consent of the 
subject, legal representative or person with the right to consent is completely free of his 
own will, he shall sign and date the subject's consent form. 
(4) No one involved in the research may be a witness. 
(5) If a fingerprint , cross or other symbol is used to sign the document, the two signatures 
on the document will also have the same effect as the signature. 
4. 
Instructions for the order of signatures of those with the right to consent: 
＊ Article 12 of the Human Body Research Act: Except for fetuses or corpses, research 
objects are limited to adults with meaningful abilities. However, this does not apply to 
those who are obviously beneficial to a specific population group or cannot be replaced 
by other research objects. When the research object is an adult with the proviso of the 
preceding paragraph, the consent of the related person shall be obtained in the following 
order: 
1. 
spouse. 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 10 
2. 
adult children. 
3. 
parents. 
4. 
brothers and sisters. 
5. 
grandparents. 
According to the written consent of the related party in the preceding paragraph, the 
written consent can be carried out by one person; if the related parties express 
disagreement, the order of each item in the preceding paragraph shall be determined. For 
persons in the same order as mentioned in the preceding paragraph, those who are close 
relatives take precedence; for those who are on the same level of kinship, the cohabiting 
relatives take precedence; for those without cohabiting relatives, the elders take 
precedence. 
P. 
Sign 
1. 
The trial host, or the co-host or its authorized personnel has explained in detail the nature 
and purpose of the above-mentioned research methods in this research plan, as well as the 
possible dangers and benefits. 
Trial host/co-host signature: ____________ 
Date: ________________________ 
Signatures of other researchers who participated in the presentation and discussion 
during the consent process: ____________ 
Date: ________________________ 
2. 
After the explanation, I have a detailed understanding of the above-mentioned research 
methods and possible risks and benefits, and I have also received detailed explanations 
about the questions about this experimental plan. I agree to accept and voluntarily 
participate in this study and will have a copy of the consent form. 
Subject signature:                       Date: ________________________ 
Telephone: 
＊ When the subject of the case meets the item (2) of [Signing Instructions for Consent 
Letter], the signature in this field must be completed. 
 
3. 
Signature of legal representative/person with consent:             
Date: ________________________ 

Version date: (Version 5 , 06/01/2022) 
Buddhist Tzu Chi Medical Foundation Hualien Tzu Chi Hospital 
Consent Form for Clinical Trial Subjects 
Form Number Version E6L0021514-11 
Page 11 
Relationship with subject (please circle) :  
self, spouse, father, mother, son, daughter, others: _________ 
Telephone: 
＊ The subject of the case meets the item (3) of [Signing Instructions for Consent Letter] , 
the signature in this field must be completed. 
4. 
Witness 1 Signature: ____________________________ Date: __________________ 
Telephone: 
Witness 2 Signature: ____________________________ Date: __________________ 
Telephone: