Program 3350-S Page 1 of 14 

Specifications by JG 

Reviewed by RG 

U.S. GOVERNMENT PUBLISHING OFFICE 

Virginia Beach, VA 

GENERAL TERMS, CONDITIONS, AND SPECIFICATIONS 

For the Procurement of 

Various Envelopes 

as requisitioned from the U.S. Government Publishing Office (GPO) by the 

DLA Document Services 

Norfolk, VA 

Single Award 

TERM OF CONTRACT: The term of this contract is for the period beginning Date of Award and ending October 

31, 2018, plus up to four (4) optional 12-month extension periods that may be added in accordance with the “OPTION 

TO EXTEND THE TERM OF THE CONTRACT” clause in SECTION 1 of this contract. 

BID OPENING: Bids shall be publicly opened at 2:00 p.m., Eastern Standard Time, on October 25, 2017. 

BID SUBMISSION: Submit bid in pre-addressed envelope furnished with solicitation or send to: U.S. Government 

Publishing Office, 291 Independence Boulevard, Suite 401, Virginia Beach, VA 23462. Facsimile bids in response to 

this solicitation are permitted. Facsimile bids may be submitted directly to the GPO Virginia Beach, VA Regional 

Office, Fax No. (757) 490-7950. The program number and bid opening date must be specified with the bid. Refer to 

Facsimile Bids in Solicitation Provisions of GPO Contract Terms, GPO Publication 310.2, as revised June 2001. 

NOTE: FAXED BIDS RECEIVED AFTER 2:00 P.M. ON THE BID OPENING DATE SPECIFIED ABOVE 

WILL NOT BE CONSIDERED FOR AWARD. 

Do NOT fax double sets or extra copies of forms that have not been requested; only fax the pages in SECTION 4 of 

these specifications, with all of the information completed as requested. 

Abstracts of contract prices are available at: 

https://www.gpo.gov/gpo/abstracts/abstract.action?region=VirginiaBeach

For information of a technical nature, contact Richard Gilbert at rgilbert@gpo.gov or (757) 490-7944. 

SECTION 1. – GENERAL TERMS AND CONDITIONS
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GPO CONTRACT TERMS: Any contract which results from this Invitation for Bid will be subject to the applicable 

provisions, clauses, and supplemental specifications of GPO Contract Terms (GPO Publication 310.2, effective 

December 1, 1987 (Rev. 6-01)) and GPO Contract Terms, Quality Assurance through Attributes Program for Printing 

and Binding (GPO Publication 310.1, effective May 1979 (Rev. 8-02)). 

GPO Contract Terms (GPO Publication 310.2) – http://www.gpo.gov/pdfs/vendors/sfas/terms.pdf. 

GPO QATAP (GPO Publication 310.1) – http://www.gpo.gov/pdfs/vendors/sfas/qatap.pdf. 

DISPUTES: GPO Publication 310.2, GPO Contract Terms, Contract Clause 5. Disputes, is hereby replaced with the 

June 2008 clause found at www.gpo.gov/pdfs/vendors/contractdisputes.pdf. 

QUALITY ASSURANCE LEVELS AND STANDARDS: The following levels and standards shall apply to these 

specifications: 

Product Quality Levels: 

(a) Printing (page related) Attributes – Level III. 

(b) Finishing (item related) Attributes – Level III. 

Inspection Levels (from ANSI/ASQC Z1.4): 

(a) Non-destructive Tests – General Inspection Level I. 

(b) Destructive Tests – Special Inspection Level S-2. 

Specified Standards: The specified standards for the attributes requiring them shall be: 

 Attribute Specified Standard 

P-7. Type Quality and Uniform Typewritten copy/Sample/Electronic media 

P-9. Solid and Screen Tint Color Match Pantone Matching System 

OPTION TO EXTEND THE TERM OF THE CONTRACT: The Government has the option to extend the term of 

this contract for a period of 12 months by written notice to the contractor not later than 30 days before the contract 

expires. If the Government exercises this option, the extended contract shall be considered to include this clause, 

except, the total duration of the contract may not exceed five (5) years as a result of, and including, any extension(s) 

added under this clause. Further extension may be negotiated under the “EXTENSION OF CONTRACT TERM” 

clause. See also “ECONOMIC PRICE ADJUSTMENT” for authorized pricing adjustment(s). 

EXTENSION OF CONTRACT TERM: At the request of the Government, the term of any contract resulting from 

this solicitation may be extended for such period of time as may be mutually agreeable to the GPO and the contractor. 

ECONOMIC PRICE ADJUSTMENT: The pricing under this contract shall be adjusted in accordance with this 

clause, provided that in no event will any pricing adjustment be made that would exceed the maximum permissible 

under any law in effect at the time of the adjustment. There will be no adjustment for orders placed during the first 

period specified below. Pricing will thereafter be eligible for adjustment during the second and any succeeding 

performance period(s). For each performance period after the first, a percentage figure will be calculated as described 

below and that figure will be the economic price adjustment for that entire next period. Pricing adjustments under this 

clause are not applicable to reimbursable postage or transportation costs, or to paper, if paper prices are subject to 

adjustment by separate clause elsewhere in this contract. 
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For the purpose of this clause, performance under this contract will be divided into successive periods. The first period 

will extend from Date of Award to September 30, 2018, and the second and any succeeding period(s) will extend for 

12 months from the end of the last preceding period, except that the length of the final period may vary. The first day 

of the second and any succeeding period(s) will be the effective date of the economic price adjustment for that period. 

Pricing adjustments in accordance with this clause will be based on changes in the seasonally adjusted “Consumer 

Price Index For All Urban Consumers - Commodities Less Food” (Index) published monthly in the CPI Detailed 

Report by the U.S. Department of Labor, Bureau of Labor Statistics. 

The economic price adjustment will be the percentage difference between Index averages as specified in this 

paragraph. An index called the variable index will be calculated by averaging the monthly Indexes from the 12-month 

interval ending three (3) months prior to the beginning of the period being considered for adjustment. This average is 

then compared to the average of the monthly Indexes for the 12-month interval ending July 31, 2017, called the base 

index. The percentage change (plus or minus) of the variable index from the base index will be the economic price 

adjustment for the period being considered for adjustment. 

The Government will notify the contractor by contract modification specifying the percentage increase or decrease to 

be applied to invoices for orders placed during the period indicated. The contractor shall apply the percentage 

increase or decrease against the total price of the invoice less reimbursable postage or transportation costs and 

separately adjusted paper prices. Payment discounts shall be applied after the invoice price is adjusted. 

PREAWARD SURVEY: In order to determine the responsibility of the prime contractor or any subcontractor, the 

Government reserves the right to conduct an on-site preaward survey at the contractor’s/subcontractor’s facility or to 

require other evidence of technical, production, managerial, financial, and similar abilities to perform, prior to the 

award of a contract. 

ASSIGNMENT OF JACKETS, PURCHASE AND PRINT ORDERS: A GPO jacket number will be assigned and 

a purchase order issued to the contractor to cover work performed. The purchase order will be supplemented by an 

individual print order for each job placed with the contractor. The print order, when issued, will indicate the quantity 

to be produced and any other information pertinent to the particular order. 

ORDERING: Items to be furnished under the contract shall be ordered by the issuance of print orders by the 

Government. Orders may be issued under the contract from Date of Award through September 30, 2018, plus for such 

additional period(s) as the contract is extended. All print orders issued hereunder are subject to the terms and 

conditions of the contract. The contract shall control in the event of conflict with any print order. A print order shall 

be “issued” upon notification by the Government for purposes of the contract when it is electronically transmitted or 

otherwise physically furnished to the contractor in conformance with the schedule. 

REQUIREMENTS: This is a requirements contract for the items and for the period specified herein. 

Shipment/delivery of items or performance of work shall be made only as authorized by orders issued in accordance 

with the clause entitled “ORDERING.” The quantities of items specified herein are estimates only, and are not 

purchased hereby. Except as may be otherwise provided in this contract, if the Government’s requirements for the 

items set forth herein do not result in orders in the amounts or quantities described as “estimated”, it shall not 

constitute the basis for an equitable price adjustment under this contract. 

Except as otherwise provided in this contract, the Government shall order from the contractor all the items set forth 

which are required to be purchased by the Government activity identified on page 1. 

The Government shall not be required to purchase from the contractor, requirements in excess of the limit on total 

orders under this contract, if any. 

Orders issued during the effective period of this contract and not completed within that time shall be completed by the 

contractor within the time specified in the order, and the rights and obligations of the contractor and the Government 
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respecting those orders shall be governed by the terms of this contract to the same extent as if completed during the 

effective period of this contract. 

If shipment/delivery of any quantity of an item covered by the contract is required by reason of urgency prior to the 

earliest date that shipment/delivery may be specified under this contract, and if the contractor will not accept an order 

providing for the accelerated shipment/delivery, the Government may procure this requirement from another source. 

The Government may issue orders which provide for shipment/delivery to or performance at multiple destinations. 

Subject to any limitations elsewhere in this contract, the contractor shall furnish to the Government all items set forth 

herein which are called for by print orders issued in accordance with the “ORDERING” clause of this contract. 

PAYMENT: Submitting invoices for payment via the GPO fax gateway (if no samples are required) utilizing the 

GPO barcode coversheet program application is the most efficient method of invoicing. Instruction for using this 

method can be found at the following web address: 

http://winapps.access.gpo.gov/fms/vouchers/barcode/instructions.html. 

Invoices may also be mailed to: U.S. Government Publishing Office, Office of Financial Management, Attn: 

Comptroller, Stop: FMCE, Washington, DC 20401. 

For more information about the billing process refer to the General Information of the Office of Finance web page 

located at https://www.gpo.gov/finance/index.htm. 

Contractor’s billing invoice must be itemized in accordance with the line items in the “SCHEDULE OF 

PRICES.” 
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SECTION 2. – SPECIFICATIONS 

SCOPE: These specifications cover the production of various envelopes requiring such operations as electronic 

prepress, printing, construction, packing, and distribution. 

TITLE: Various Envelopes. 

FREQUENCY OF ORDERS: Approximately 25 to 75 orders per year. 

QUANTITY: Approximately 100 to 50,000 envelopes per order. 

NOTE: Up to three different envelopes may be ordered on the same print order requiring the same schedule. Majority 

of orders placed will be for one envelope only. 

TRIM SIZES: Trim sizes required are as follows – 

No. 9 (3-7/8 x 8-7/8”), plus flap 

No. 10 (4-1/8 x 9-1/2”), plus flap 

No. 11 (4-1/2 x 10-3/8”), plus flap 

6 x 9-1/2”, plus flap 

8-1/2 x 11-1/2”, plus flap 

9 x 12”, plus flap 

9-1/2 x 12”, plus flap 

9-1/2 x 12-1/2”, plus flap 

10 x 15”, plus flap 

12 x 16”, plus flap 

NOTE: No. 9, No. 10, and No. 11 envelopes may be ordered with or without windows, and with or without security 

tint. 

GOVERNMENT TO FURNISH: Typewritten and handwritten manuscript copy, sample envelopes, negatives, or 

MS Word file may be furnished. (NOTE: When furnished, the MS Word file (latest version) will be emailed to the 

contractor.) 

Identification markings such as register marks, commercial identification marks of any kind, etc., carried in the 

furnished copy, negatives, or electronic files, must not print on finished product. 

CONTRACTOR TO FURNISH: All materials and operations, other than those listed under “GOVERNMENT TO 

FURNISH,” necessary to produce the product in accordance with these specifications. 

COMPOSITION: Approximately 40% of all orders placed will require the contractor to set up to 7 to 10 lines of 

type and/or 2 horizontal rules. 

Type must be set in Helvetica 6 through 72 pt. 

While the above typeface is preferred, suitable alternates of comparable weight, face, and size will be considered. If 

an alternate typeface is proposed, the bidder shall list in his bid the name of the alternate typeface(s) and composing 

machine to be used. 

The Government reserves the right to require sample and to judge the suitability of any alternate typeface offered in 

order to make an award which is deemed to be in the best interest of the Government. 

PROOFS: When ordered, one (1) Adobe Acrobat (current version) PDF soft proof. Proof will be transferred to the 

agency via email. The PDF proof will be evaluated for text flow, image position, and color breaks. Proof will not be 

used for color match. 
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If any contractor’s errors are serious enough in the opinion of the GPO to require revised proofs, the revised proofs are 

to be provided at no expense to the Government. No extra time can be allowed for this reproofing; such operations 

must be accomplished within the original production schedule allotted in the specifications. 

The contractor must not print prior to receipt of an “OK to print.” 

STOCK/PAPER: The specifications of all paper furnished must be in accordance with those listed herein or listed 

for the corresponding JCP Code numbers in the “Government Paper Specification Standards No. 12” dated March 

2011. 

Government Paper Specification Standards No. 12 – http://www.gpo.gov/pdfs/customers/sfas/vol12/vol_12.pdf. 

All text stock used in each copy must be of a uniform shade. All cover stock must have the grain parallel to the spine. 

No. 9, No. 10, and No. 11 Envelopes – White Wove, basis weight: 24 pounds per 500 sheets, 17 x 22”. 

Balance of Envelope Sizes – Kraft (Light Brown shade and White), basis weight: 32 or 40 pounds per 500 sheets, 17 x 

22”, equal to JCP Code V10. (NOTE: The majority of orders will require the Light Brown Kraft.) 

PRINTING: Print face only (after construction) in a single ink color. NOTE: The majority of envelopes will print in 

black ink. 

Match Pantone number as indicated on the print order. 

Security tint, when indicated on print order: Inside of envelope requires a blue or black opaque security design. 

Contractor may use their own design, but must guarantee complete opacity and prevent show through of the 

contents therein. 

Envelopes shall accept printing, ink writing and bar coding without feathering, blurring, smearing, or penetrating to 

the reverse side. Printing on all envelopes shall be in accordance with the requirements for the style envelope ordered. 

All printing shall comply with all applicable USPS Regulations. 

NOTE: The GPO imprint requirement is waived. 

MARGINS: Maintain margins as indicated on print order or furnished copy. 

CONSTRUCTION: Envelopes shall be open end or open side, high-cut, diagonal or side seams with gummed flap, 

as specified on the print order. 

Envelopes shall be sufficiently high cut so as to prevent the flap adhesive from adhering to the envelope contents. The 

sealed seam shall not adhere to the inside of the envelope. Envelopes shall be free from cuts, folds, tears, machine 

marks, foreign matter, dirt, ink smears, and adhesive stains. Some envelope will require a split glue flap. 

Some envelopes may require one die-cut window. Size and location of the window will be indicated on the print order 

and must meet criteria specified in the U.S. Postal Service Publication 25. The print order will show the type of 

window, size of window, and indicate whether window corners are to be rounded or slightly rounded. 

NOTE: On an occasional order, the contractor may be required to trim off the top flap. 

PACKING: Box in suitable units or as indicated on the print order. Pack in shipping containers. 

LABELING AND MARKING: Reproduce shipping container label from furnished repro, fill in appropriate blanks 

and attach to shipping containers. 
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DEPARTMENTAL RANDOM COPIES (BLUE LABEL): All orders must be divided into equal sublots in 

accordance with the chart below. A random copy must be selected from each sublot. Do not choose copies from the 

same general area in each sublot. The contractor will be required to execute a statement furnished by GPO certifying 

that copies were selected as directed. The random copies constitute a part of the total quantity ordered, and no 

additional charge will be allowed. 

 Quantity Number of 

 Ordered Sublots 

 500 - 3,200 50 

 3,201 - 10,000 80 

 10,001 - 35,000 125 

 35,001 and over 200 

These randomly selected copies must be packed separately and identified by a special government-furnished blue 

label, affixed to each affected container. The container and its contents shall be recorded separately on all shipping 

documents and sent in accordance with the distribution list. 

A copy of the PRINT ORDER/SPECIFICATION and a signed Government-furnished certificate of selection, must be 

included. 

A copy of the Government furnished certificate must accompany the voucher sent to GPO, Financial Management 

Services, for payment. Failure to furnish the certificate may result in delay in processing the voucher. 

QUALITY ASSURANCE RANDOM COPIES: In addition to the Departmental Random Copies (Blue Label), the 

contractor may be required to submit quality assurance random copies to test for compliance against the specifications. 

 The print order will indicate the number required, if any. When ordered, the contractor must divide the entire order 

into equal sublots and select a copy from a different general area of each sublot. The contractor will be required to 

execute a statement furnished by GPO certifying that copies were selected as directed. Copies will be paid for at the 

running rate offered in the contractor’s bid and their cost will not be a consideration for award. 

Business Reply Mail labels will be furnished for mailing the quality assurance random copies. The copies are to be 

mailed at the same time as the first scheduled shipment. A copy of the print order must be included. 

A U.S. Postal Service approved Certificate of Mailing, identified by Program, Jacket, and Print Order numbers, must 

be furnished with billing as evidence of mailing. 

DISTRIBUTION: Deliver f.o.b. destination to one of several different addresses in Norfolk, VA or Portsmouth, VA. 

(NOTE: There is only one delivery address per print order; however, the address for each print order may be 

different.) 

An occasional order may require the contractor to ship f.o.b. contractor’s city to an address outside Norfolk, VA, or 

Portsmouth, VA. When required, the contractor is to ship (reimbursable) by traceable means. Contractor will be 

reimbursed for all shipping costs by submitting all shipping receipts with billing invoice for payment. 

Complete addresses and quantities will be furnished with the print orders. 

Upon completion of each order, the contractor must notify the ordering agency on the same day that the product 

delivers/ships via email to the address specified on the print order. The subject line of the email shall be “Distribution 

Notice for Program 3350-s, P.O. EXXXX, Print Order XXXXX.” The notice must provide all applicable tracking 

numbers, shipping method, and title. Contractor must be able to provide copies of all delivery and shipping receipts 

upon agency request. 
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Upon completion of each order, contractor must return all furnished materials to the delivery address (in either 

Norfolk, VA or Portsmouth, VA) as specified on the print order. 

All expenses incidental to picking up and returning materials, submitting proofs, and furnishing sample copies must be 

borne by the contractor. 

SCHEDULE: Adherence to this schedule must be maintained. Contractor must not start production of any job prior to 

receipt of the individual print order (GPO Form 2511). 

Furnished material must be picked from and delivered to one address in Norfolk, VA or one address in Portsmouth, 

VA. 

PDF soft proofs must be emailed to the address specified on the print order. 

No definite schedule for pickup of material can be predetermined. 

The following schedule begins the workday after notification of the availability of print order and furnished material; 

the workday after notification will be the first workday of the schedule. 

 Contractor to submit proofs within three (3) workdays of notification of availability of print order and 

furnished materials. 

 Proofs will be withheld no more than two (2) workdays from their receipt at the ordering agency. (The first 

workday after receipt of proofs at the ordering agency is day one (1) of the hold time.) 

NOTE: Agency will email corrections, revisions, and/or “O.K. to print.” 

 Complete production and distribution must be made within five (5) workdays of receipt of an “OK to print” 

on proofs. 

The ship/deliver date indicated on the print order is the date products ordered for delivery f.o.b. destination must be 

delivered to the destination(s) specified. 

Unscheduled material such as shipping documents, receipts or instructions, delivery lists, labels, etc., will be furnished 

with the order or shortly thereafter. In the event such information is not received in due time, the contractor will not 

be relieved of any responsibility in meeting the shipping schedule because of failure to request such information. 
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SECTION 3. - DETERMINATION OF AWARD 

The Government will determine the lowest bid by applying the prices offered in the “SCHEDULE OF PRICES” to the 

following units of production which are the estimated requirements to produce one (1) year’s production under this 

contract. These units do not constitute, nor are they to be construed as, a guarantee of the volume of work which may 

be ordered for a like period of time. 

The following item designations correspond to those listed in the “SCHEDULE OF PRICES.” 

I. (a) 18 

 (b) 5 

II. (a) 1 

 (b) 2 

 (c) 98 

 (d) 68 

 (e) 1 

 (f) 1 

 (g) 1 

 (h) 66 

 (i) 6 

 (j) 3 

 (k) 8 

 (l) 3 

 (m) 17 

 (n) 1 

 (o) 1 

 (p) 49 

 (q) 34 

 (r) 10 

III. (a) 66 

 (b) 5 
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THIS PAGE IS INTENTIONALLY BLANK.
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SECTION 4. - SCHEDULE OF PRICES 

Bids offered are f.o.b. contractor’s city for all shipping outside Norfolk, VA, and Portsmouth, VA, and f.o.b. 

destination for all other consignments. 

Prices must include the cost of all required materials and operations for each item listed in accordance with these 

specifications. 

Bidder must make an entry in each of the spaces provided, in the category or categories for which bids are submitted. 

Bids submitted with any obliteration, revision, or alteration of the order and manner of submitting bids may be 

declared nonresponsive. 

An entry of NC (No Charge) shall be entered if bidder intends to furnish individual items at no charge to the 

Government. 

An entry of NB (No Bid) must be entered if bidder does not intend to furnish certain items. 

Bids submitted with blank spaces for the individual items will be considered as an entry of NB for that particular item. 

The Contracting Officer reserves the right to reject any offer that contains prices for individual items of production 

(whether or not such items are included in the DETERMINATION OF AWARD) that are inconsistent or unrealistic in 

regard to other prices in the same offer or to GPO prices for the same operation if such action would be in the best 

interest of the Government. 

All invoices submitted to the GPO shall be based on the most economical method of production. Fractional parts of 

1,000 will be prorated at the per-1,000 rate. 

I. COMPOSITION AND PROOFS: 

 (a) Typesetting 5 to 7 lines or 2 horizontal rules ............................................. per envelope ......... $___________ 

 (b) Adobe Acrobat PDF soft proof....................................................................... .per proof ......... $___________ 

II. COMPLETE PRODUCT: Prices offered shall include the cost of all required materials and operations 

necessary for the complete production and distribution of the product listed in accordance with these 

specifications. 

Per 1,000 

Envelopes 

 

 (a) No. 9 Envelope (3-7/8 x 8-7/8) without window .................................................................. $___________ 

 (b) No. 9 Envelope (3-7/8 x 8-7/8) with window........................................................................ $___________ 

 (c) No. 10 Envelope (4-1/8 x 9-1/2) without window................................................................. $___________ 

(d) No. 10 Envelope (4-1/8 x 9-1/2) with window...................................................................... $___________ 

_______________ 

(Initials) 
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 Per 1,000 

Envelopes 

 (e) No. 11 Envelope (4-1/2 x 10-3/8) no window ....................................................................... $___________ 

 (f) No. 11 Envelope (4-1/2 x 10-3/8) with window.................................................................... $___________ 

 (g) 6 x 9-1/2 Envelope ................................................................................................................ $___________ 

 

 (h) 8-1/2 x 11-1/2 Envelope............................... ......................................................................... $___________ 

 (i) 9 x 12 Envelope ..................................................................................................................... $___________ 

 (j) 9-1/2 x 12 Envelope........................... ................................................................................... $___________ 

 (k) 9-1/2 x 12-1/2 Envelope ........................................................................................................ $___________ 

 (l) 10 x 15 Envelope ................................................................................................................... $___________ 

 (m) 12 x 16 Envelope ................................................................................................................... $___________ 

 

 (n) No. 9 Envelope (3-7/8 x 8-7/8) Security tint – no window.........................................$___________ 

 (o) No. 9 Envelope (3-7/8 x 8-7/8) Security tint – with window.......................................$___________ 

 (p) No. 10 Envelope (4-1/8 x 9-1/2) Security tint – no window........................................$____________ 

 (q) No. 10 Envelope (4-1/8 x 9-1/2) Security tint – with window.....................................$____________ 

 (r) 6-1/2 x 9-1/2 Kraft envelope............................................................................$____________ 

III. ADDITIONAL OPERATIONS:

(a) Trimming top flap................per 1,000 envelopes..............................................$___________ 

(b) Printing on flap in same color as face............per 1,000 envelopes............................$___________ 

TYPEFACES: If alternate typefaces are proposed, the bidder must list on the line of the same number as the 

preferred typeface, the name of the alternate typeface and composing machine to be used. 

Preferred Typeface: 1. Helvetica.(6 to 72 pt.) 

1. ______________________________________ _______________________________________ 

 Alternate Typeface Name of Composing Machine 

 _______________ 

(Initials) 
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INSTRUCTIONS FOR BID SUBMISSION: Fill out “SECTION 4.-SCHEDULE OF PRICES,” initialing or 

signing each page in the space(s) provided. Submit two copies (original and one exact duplicate) of the “SCHEDULE 

OF PRICES” with two copies of the GPO Form 910 “BID” form. Do not enter bid prices on GPO Form 910; prices 

entered in the “SCHEDULE OF PRICES” will prevail. 

Bidder ____________________________________________________________________________________ 

 __________________________________________________________________________________________ 

(City - State) 

By _______________________________________________________________________________________ 

(Signature and title of person authorized to sign this bid) 

 __________________________________________________________________________________________ 

 (Person to be contacted) (Telephone Number) 

 ___________________________________________________________________________________________ 

 (Fax Number) (Email Address) 

 
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