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                                                                    EXHIBIT 4.17

ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

ACCESS INDEMNITY AND INSURANCE DEED

JAMES HARDIE INDUSTRIES LIMITED

ALLEN ALLEN & HEMSLEY
The Chifley Tower
2 Chifley Square
Sydney NSW 2000
Australia
Tel 61 2 9230 4000
Fax 61 2 9230 5333

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

DATE
            [Date]
PARTIES

      1.    JAMES HARDIE INDUSTRIES LIMITED (ACN 000 009 263) incorporate in New
            South Wales of Level 8, 65 York Street, Sydney NSW 2000 ("COMPANY");

            FOR THE BENEFIT OF:

      2.    [NAME] of [Address] ("COVENANTEE").

RECITALS

      A     The Constitution of the Company authorises it to grant an indemnity
            to the directors and other officers of the Company.

      B     The Covenantee is a director or alternate director of the Company.

      C     The Company and the Covenantee agree to enter into this Deed, to
            grant an indemnity to the Covenantee which will continue after the
            expiry of his period of office, and to specify the Covenantee's
            rights to be insured and to obtain access to the Books of the
            Company.

IT IS AGREED as follows.

1.    DEFINITIONS AND INTERPRETATION

1.1   DEFINITIONS

      In this Deed, the following words have the following meanings unless
      otherwise required by the context or subject matter:

      AMENDMENT DATE means the effective date of the amendments to the Company's
      Constitution, as approved by its members at its general meeting on 13 July
      2000.

      APPOINTMENT DATE means the date the Covenantee became an Officer, having
      consented to act in that capacity.

      ASIC means the Australian Securities and Investments Commission.

      BOARD means the board of directors of the Company.

      BOOKS has the meaning set out in section 9 of the Corporations Law.

      CLAIM means any claim made or proceedings brought against the Covenantee
      or any inquiry by a Governmental Agency in which the Covenantee becomes
      involved or is required to appear, in each case, in the Covenantee's
      capacity as a director of the Company or any of its related bodies
      corporate.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

      DELIBERATIONS includes meeting of, and communications or discussions
      between, members of the Board, and committees on which members of the
      Board sit, and any decisions, resolutions or directives made at those
      meetings or discussions.

      DOCUMENT means any of the following:

      (a)   a document as defined in section 9 of the Corporations Law:

      (i)   delivered to members of the Board for use in Deliberations;

      (ii)  used in Deliberations or referred to in Deliberations; or

      (iii) which is reasonably material to Deliberations;

      (b)   any written advice or opinion from a solicitor or barrister
            addressed to both an Officer and the Company;

      (c)   any written advice or opinion from a solicitor or barrister where
            the advice or opinion is expressed to be for the benefit of or to be
            relied on by any Officer, either as an Officer or in their personal
            capacity, even if the advice or opinion is addressed only to the
            Company;

      (d)   a document as defined in section 9 of the Corporations Law which is
            referred to or mentioned in any document referred to in paragraphs
            (a), (b) or (c) above.

      GOVERNMENTAL AGENCY means any government or any governmental,
      semi-governmental, or judicial entity or authority. It also includes any
      self regulatory organisation established under statute, any stock exchange
      or any committee of any state, territory or national parliament of any
      jurisdiction,

      OFFICER has the meaning given in section 9 of the Corporations Law.

      PERSON has the meaning as appears in section 9 of the Corporations Law.

      SUBSIDIARY means a body corporate, all the issued share capital of which
      is held directly or indirectly by the Company (excluding any part of that
      issued share capital that carries no right to participate beyond a
      specified amount in a distribution of either profits or capital).

1.2   INTERPRETATION

      Headings are for convenience only and do not affect interpretation. The
      following rules of interpretation apply unless the context requites
      otherwise.

      (a)   A reference to the COMPANY includes the company's administrators,
            liquidators, receivers, receivers and managers, representatives, and
            successors.

      (b)   A reference to the COVENANTEE includes the Covenantee's estate,
            administrators, executors and personal representatives.

      (c)   A reference to any LEGISLATION or to any provision of any
            legislation includes any modification or re-enactment of it, any
            legislative provision substituted for it and all regulations and
            statutory instruments issued under it.

      (d)   The singular includes the plural and conversely.

      (e)   A gender includes all genders.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

      (f)   A reference to CLAUSE is to a clause of this Deed.

      (g)   The use of INCLUDE, INCLUDES or INCLUDING does not limit what else
            might be included.

      (h)   Words or phrases having a particular meaning for the purposes of the
            Corporations Law have the same meaning in this Deed.

2.    ACKNOWLEDGEMENT BY COMPANY

      The Company provides the indemnity, allows the access to the Books of the
      Company and incurs the other obligations under this Deed in consideration
      for the Covenantee agreeing to act, or continue to act, as the case may
      be, as an Officer of the Company.

3.    DUTIES OF COVENANTEE

      On and from the Appointment Date the Covenantee must carry out the duties
      of his or her office in accordance with all applicable laws.

4.    INDEMNITY

4.1   INDEMNITY

      To the extent permitted by law and without limiting the powers of the
      Company, the Company indemnifies the Covenantee from and against all
      liabilities which result directly or indirectly from facts or
      circumstances, whether arising before, on or after the Amendment Date,
      relating to the Covenantee serving or having served in his or her capacity
      as an Officer of the Company or a related body corporate of the Company
      (as defined in the Corporations Law):

      (a)   to any person, other than:

            (i)   a liability owed to the Company or a related body corporate;
                  or

            (ii)  a pecuniary penalty order or compensation order under the
                  Corporations Law; or

            (iii) a liability that is owed to someone (other than the Company or
                  a related body corporate) and did not arise out of conduct in
                  good faith,

      (but this paragraph (a) does not apply to legal costs);

      (b)   for legal costs incurred by the Covenantee in defending or resisting
            proceedings for a liability if the costs are incurred other than:

            (i)   in defending or resisting civil proceedings in which the
                  Covenantee is found to have a liability for which they could
                  not be indemnified under paragraph (a); or

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

            (ii)  in defending or resisting criminal proceedings in which the
                  Covenantee is found guilty; or

            (iii) in defending or resisting proceedings brought by ASIC or a
                  liquidator for a court order if the grounds for making the
                  order are found by the court to be established; or

            (iv)  in connection with proceedings for relief to the Covenantee
                  under the Corporations Law in which the court denies relief to
                  the Covenantee.

      Clause 4.1(b)(iii) does not apply to costs incurred by the Covenantee in
      responding to actions brought by ASIC or a liquidator as part of an
      investigation, before commencing proceedings for the court order.

4.2   SEPARATE LEGAL REPRESENTATION

      If, in respect of a Claim, the Company elects to conduct the litigation
      under Clause 8.6, then the Company may decide, with proper regard to the
      interests of the Covenantee, to indemnify or refuse to indemnify (subject
      to Clause 8.1) the Covenantee with respect to any separate legal or other
      representation engaged by the Covenantee to advise or assist with the
      Covenantee's participation in the Claim.

4.3   IMPACT OF TAXATION - COMPULSORY GROSSING UP

      The amount of any indemnity payment to the Covenantee must be calculated
      having regard to the impact of taxation laws on the Covenantee in relation
      to any payment required to be made by, or to, the Covenantee, with the
      intention of ensuring that the Covenantee is placed in the same after tax
      position as if the liability to which the indemnity payment relates had
      not been incurred. In particular, and to the extent necessary to achieve
      this intention, an indemnity payment required to be made to the Covenantee
      under Clause 4.1 must be grossed up for any income tax incurred by the
      Covenantee in respect of it (after taking into account any allowable
      deductions available to the Covenantee in respect of the liability to
      which the indemnity payment relates).

4.4   GST GROSS UP

      If all or part of any payment made under this Deed is the GST exclusive
      consideration for a taxable supply for GST purposes, the person making the
      payment must pay to the recipient an additional amount equal to that
      payment (or part) multiplied by the appropriate rate of GST (which is
      currently 10%).

4.5   PAYMENT

      The Company shall within 14 days of a written demand from the Covenantee
      made from time to time pay the Covenantee the amount which is payable
      under this Deed. A demand made by the Covenantee under this Clause shall
      contain reasonable details of the amounts payable by the Company.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

4.6   REPAYMENT

      The Covenantee undertakes to repay the Company any amount paid by the
      Company under Clause 4.5 if, and only to the extent that:

      (a)   a court of competent jurisdiction determines that the Covenantee is
            not entitled to be indemnified by the Company for such liabilities;
            or

      (b)   the Covenantee receives payment under a contract of insurance
            procured by the Company or any other person in respect of those
            liabilities or the insurer has paid, discharged and satisfied those
            liabilities directly; or

      (c)   the Company pays an amount to the Covenantee in excess of the amount
            actually payable by way of indemnity under Clause 4.1 or under the
            indemnity set out in the Company's constitution.

4.7   INDEMNITY GIVEN IN ADDITION TO ANY OTHER INDEMNITY

      The indemnity under this Deed is given to the Covenantee in addition to
      any other indemnity given by the Company to the Covenantee whether by way
      of agreement, under the Company's constitution, by statute or otherwise,
      but nothing in this Deed requires the Company to pay more than once in
      respect of any Claim.

4.8   INDEMNITY AFTER COVENANTEE CEASES TO BE AN OFFICER

      The indemnity given by the Company under this Deed shall be in force and
      shall continue for 7 years from the date from which the Covenantee ceases
      to be an Officer and during that period it shall be irrevocable and shall
      not be affected by:

      (a)   any intermediate payments, settlement of accounts or payment;

      (b)   laches, acquiescence or delay on the part of the Covenantee;

      (c)   the death, bankruptcy, insolvency or liquidation of any Person; or

      (d)   any other thing or matter which might otherwise affect it whether in
            law or equity.

5.    COMPANY TO PAY INSURANCE PREMIUM

      (a)   The Company agrees to procure and pay the premium for and maintain
            in full force and effect a contract of insurance from an established
            and reputable insurer, or, if appropriate, through a properly
            established and maintained self-insurance program, which insures the
            Covenantee against all liabilities incurred by the Covenantee
            directly or indirectly as an Officer of the Company or a related
            body corporate, provided that:

            (i)   the provisions of the Corporations Law including, but not
                  limited to, Part 2D.2 is complied with in regard to the above;
                  and

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

            (ii)  the liability does not arise out of conduct involving a wilful
                  breach of duty to the Company or to a related body corporate
                  or a contravention of sections 182 or 183 of the Corporations
                  Law.

      (b)   The insurance contract referred to in paragraph (a) must provide
            insurance against liability for costs and expenses incurred by the
            Covenantee in defending or resisting proceedings, whether civil or
            criminal and whatever their outcome.

      (c)   Unless the Company agrees otherwise, the insurance contract referred
            to in paragraph (a) will contain a provision waiving all rights of
            subrogation or action by the Covenantee against the Company.

      (d)   If a notice has been given to the insurer as referred to in Clause
            8, the Company must take all steps reasonably necessary or desirable
            in order to cause the insurer to pay to the Covenantee all amounts
            payable under the contract of insurance in connection with any claim
            or proceeding against the Covenantee.

      (e)   The Company must provide to the Covenantee a copy of all contracts
            of insurance procured by the Company pursuant to this clause which
            insure the Covenantee within 30 days of request by the Covenantee.

      (f)   The Company will use its best endeavours to ensure that it does not
            do anything which will

            (i)   render void any contract of insurance maintained under this
                  Clause; or

            (ii)  entitle an insurer of such a contract of insurance to refuse
                  the payment of a claim or to reduce the amount of the claim
                  being paid.

6.    INSURANCE AFTER COVENANTEE CEASES TO BE AN OFFICER

6.1   DURATION OF INSURANCE

      The obligations of the Company referred to in Clause 5 shall continue for
      7 years from the date from which the Covenantee ceases to be an Officer of
      the Company.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

6.2   SAME COVERAGE

      If the Covenantee has ceased to be an Officer of the Company, a contract
      of insurance procured by the Company pursuant to Clause 5 and the previous
      paragraph must provide insurance to the same extent and in relation to the
      same liabilities as contracts of insurance procured and paid for by the
      Company for the benefit of other persons who are, at the time the
      contracts of insurance are procured pursuant to this clause, Officers, or
      if there are no such contracts of insurance then to the same extent and in
      relation to the same liabilities as the contract of insurance applicable
      to the Covenantee immediately prior to ceasing to be an Officer.

7.    DISCLOSURE IN DIRECTORS' REPORT

      The Covenantee and the Company agree that, subject to any exception
      provided for in the Corporations Law or granted or approved by ASIC, full
      particulars of the Company's indemnities and insurance premiums in
      relation to the Covenantee will be included each year in the Directors'
      report in compliance with the requirements of the Corporations Law.

8.    NOTIFICATION AND CONDUCT OF CLAIMS

8.1   OBLIGATIONS ON COVENANTEE

      When the Covenantee wishes to obtain the benefit of this indemnity, the
      Covenantee must:

      (a)   give notice to the Company promptly upon becoming aware of any Claim
            or any circumstances which give rise or could give rise to a Claim;

      (b)   take such reasonable action as the Company requests to avoid,
            dispute, resist, bring an appeal on, compromise or defend any Claim
            or any adjudication of any Claim;

      (c)   not settle or compromise any Claim or make any admission of
            liability or payment in relation to any Claim without the prior
            written consent of the Company which must not be unreasonably
            withheld; and

      (d)   upon request by the Company, render all reasonable assistance and
            co-operation to the Company in the conduct of the Claim, including
            providing the Company with any documents, authorities and directions
            that the Company may reasonably require.

      The Covenantee is entitled to be reimbursed by the Company for actual
      costs reasonably incurred by the Covenantee in taking action pursuant to
      Clause 8.1.

8.2   LIMIT ON COVENANTEE'S OBLIGATIONS

      If the Covenantee complies with Clause 8.1(a) and either the Company
      fails to make a

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

      payment in respect of the indemnity set out in Clause 4.1 or refuses to
      acknowledge that it is liable to indemnify the Covenantee in respect of
      the Claims under Clause 4.1, then the Covenantee is not obliged to comply
      with Clauses 8.1(b), (c) or (d).

8.3   NOTIFICATION OF INSURER

      If the Covenantee gives a notice under Clause 8.1 to the Company, the
      Company must promptly give to the insurer referred to in Clause 5 a
      written notice in substantially the same terms and which complies with the
      terms and conditions of the insurance contract procured by the Company.

8.4   OBLIGATIONS ON COMPANY TO NOTIFY COVENANTEE

      The Company must notify the Covenantee in writing as soon as reasonably
      practicable after becoming aware of any Claim or circumstances which give
      rise or could give rise to a Claim, including if any Claim is threatened
      or made against the Company which may result in the Claim being made
      against the Covenantee.

8.5   RELIEF FOR THE COMPANY

      If, in relation to a Claim, and subject to Clause 8.2, the Covenantee has
      failed to perform an obligation under Clause 8.1 to the material prejudice
      of the Company in relation to that Claim, the Company is relieved from
      each and every obligation owed under this Deed in respect of the Claim to
      the Covenantee.

8.6   CONDUCT OF LITIGATION WHERE THE COMPANY ADMITS LIABILITY

      If the Company:

      (a)   acknowledges and gives written notice to the Covenantee that it is
            liable to indemnify the Covenantee in respect of a Claim under
            Clause 4.1;

      (b)   provides adequate security for all legal and other costs in
            connection with the defence of that Claim and any related
            proceedings and pays such costs as they arise;

      (c)   satisfies, and continues to satisfy, the Covenantee of its financial
            ability to indemnify the Covenantee; and

      (d)   obtains legal advice from senior counsel experienced in the relevant
            area that there is a reasonable prospect of successfully defending
            that Claim and Counsel remains of that view,

      the Company shall be entitled to conduct the defence of such a Claim under
      its sole management and control and at its sole cost and, for that
      purpose, to institute such legal and other proceedings (including
      cross-claims) in the name of the Covenantee as it thinks fit. However:

      (e)   the Company will have regard to the principle that the reputation of
            the Covenantee should not be unnecessarily injured; and

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

      (f)   the Company must not settle that Claim without the prior written
            approval of the Covenantee, or instruct the Covenantee to do so,
            unless the Company has first satisfied the Covenantee that moneys
            are available to pay the settlement amount.

      For so long as the Company is entitled to conduct the defence of a Claim,
      the Covenantee must promptly render all reasonable assistance and
      co-operation to the Company in the conduct of the relevant proceedings.

9.    MAINTENANCE OF AND ACCESS TO DOCUMENTS

9.1   MAINTENANCE OF DOCUMENTS

      The Company must keep and maintain in chronological order a complete set
      of all Documents relating to the period of time the Covenantee is an
      Officer of the Company or a related body corporate. The company secretary
      from time to time of the Company will have the responsibility of
      maintaining this set of Documents and ensuring that the Documents are kept
      in safe and secure custody.

9.2   ACCESS TO DOCUMENTS

      (a)   The Covenantee may, while being an Officer of the Company, inspect
            the Books of the Company (other than its financial records) at all
            reasonable times for the purposes of a legal proceeding or any ASIC
            or liquidator investigation:

            (i)   to which the Covenantee is a party; or

            (ii)  that the Covenantee proposes in good faith to bring; or

            (iii) that the Covenantee has reason to believe will be brought
                  against him or her.

      (b)   The Covenantee may, while being an Officer of the Company, inspect
            its financial records at all reasonable times.

      (c)   The Covenantee may, for a period of 7 years after ceasing to be an
            Officer of the Company, inspect the Books of the Company (including
            its financial records) at all reasonable times for the purposes of a
            legal proceeding or any ASIC or liquidator investigation:

            (i)   to which the Covenantee is a party; or

            (ii)  that the Covenantee proposes in good faith to bring; or

            (iii) that the Covenantee has reason to believe will be brought
                  against him or her.

      (d)   The Covenantee may make copies of the Books (including financial
            records) for the purposes of the legal proceeding or investigation
            referred to above.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

9.3   REQUEST FOR ACCESS

      If the Covenantee wishes to have access to the Books under Clause 9.2, the
      Covenantee must deliver to the company secretary from time to time of the
      Company a written request for such access. A request may specify
      particular documents which the Covenantee wishes to have access to or the
      request may specify documents by reference to type, date or by a general
      description. A request must include reasons for or the purpose for which
      the Covenantee wishes to have access to the Books.

9.4   RESPONSIBILITY OF COMPANY SECRETARY

      The Company must ensure that the company secretary from time to time of
      the Company will have the responsibility of:

      (a)   making arrangements with the Covenantee for the giving of access to
            the Books of the Company;

      (b)   ensuring that following receipt of a written request for access
            pursuant to Clause 9.3 above, access to the Books of the Company
            under Clause 9.2 above is given within 14 days of receipt of the
            request, or such other period as the Covenantee and the company
            secretary agree; and

      (c)   reporting to the Board all requests for access received by the
            company secretary pursuant to Clause 9.3 above.

9.5   REFUSAL OF ACCESS

      The Company may instruct the company secretary of the Company that he or
      she must, on the instructions of the Board, refuse access by the
      Covenantee if:

      (a)   access is inconsistent with the Covenantee's obligations in this
            Deed;

      (b)   access may cause waivers of the Company's or a related body
            corporate's legal professional privilege attaching to those
            Documents and access is requested by the Covenantee at a time during
            which the Covenantee and the Company or any of its related bodies
            corporate are involved or potentially involved, as determined by the
            Company acting in good faith, against each other.

9.6   RESOURCES

      The Company must provide the company secretary with adequate resources to
      discharge his responsibilities under this Clause 9.

10.   RIGHT TO KEEP DOCUMENTS

      Subject to Clause 11, the Company acknowledges that the Covenantee may
      keep and retain possession of any Document given or delivered to the
      Covenantee during the time that the Covenantee is an Officer unless:

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

      (a)   the Company reserved its right to recall the Document when the
            Document was delivered or given to the Covenantee and the Company
            has in fact recalled the Document;

      (b)   conditions regarding possession or disposal of the Document were
            attached to the Document when the Document was delivered or given to
            the Covenantee, in which case those conditions shall have effect
            according to their terms; or

      (c)   the Document is the property of a Subsidiary, in which case the
            Covenantee must return the Document and all copies of it to the
            Subsidiary upon the Covenantee ceasing to be an Officer.

11.   PRESERVATION OF CONFIDENTIALITY AND LEGAL PROFESSIONAL PRIVILEGE

11.1  CONFIDENTIALITY

      The Covenantee must keep confidential all confidential information
      contained in a document or other material included in the Books of the
      Company which the Covenantee has had access to or which the Covenantee
      possesses and the Covenantee must not divulge or release that information
      to any person other than in the course of seeking legal advice or as
      authorised in writing by the Company or as required by an order of a
      Court.

11.2  LEGAL PROFESSIONAL PRIVILEGE

      If a document or other material included in the Books of the Company which
      the Covenantee has access to or which the Covenantee possesses is the
      subject of legal professional privilege to the benefit of both the Company
      and the Covenantee, the Covenantee must not do any act or thing or omit to
      do any act or thing which act or thing or omission will cause that
      privilege to be waived, extinguished or lost.

11.3  NO LIMITATION

      Clauses 11.1 and 11.2 shall not be taken to derogate from or to limit any
      duty owed by the Covenantee to the Company.

12.   OTHER RIGHTS

      The benefits and rights provided or in favour of the Covenantee under this
      Deed shall be construed separately from and shall not derogate from any
      other rights which the Covenantee may have under any law, the Constitution
      of the Company, or otherwise and shall continue in force and effect during
      the period referred to in Clause 4.7 notwithstanding any of the events
      mentioned in that clause.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

13.   GOVERNING LAW

      This document is governed by, and is to be interpreted in accordance with,
      the laws of New South Wales, The parties submit to the non-exclusive
      jurisdiction of the courts exercising jurisdiction there.

14.   SEVERANCE

      If any part, being a word, sentence, paragraph or otherwise, of this
      document is, or becomes, void or unenforceable, that part is, or will be,
      severed from this document so that all parts that are not, or do not
      become, void or unenforceable remain in full force and effect and are
      unaffected by that severance.

15.   NOTICES

      Any notice given under this Deed:

      (a)   must be in writing addressed to the intended recipient at the
            address shown below:

      (c)   THE COMPANY:

            James Hardie Industries Limited
            65 York Street
            Sydney NSW 2000
            Attention: Company Secretary
            Fax: 9262 5758

            THE COVENANTEE:

            [Name]
            [Address]

            or the address last notified by the intended recipient to the
            sender;

      (d)   must be signed by a person duly authorised by the sender, and

      (e)   will be taken to have been given when delivered, received or left at
            the above address. If delivery or receipt occurs on a day when
            business is not generally carried on in the place to which the
            notice is sent, or is later than 4pm (local time), it will be taken
            to have been duly given at the commencement of business on the next
            day when business is generally carried on in that place.

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ACCESS INDEMNITY AND INSURANCE DEED                        ALLEN ALLEN & HEMSLEY

16.   NO WAIVER

      No failure to exercise and no delay in exercising any right, power or
      remedy under this Deed will operate as a waiver. Nor will any single or
      partial exercise of any right, power or remedy preclude any other or
      further exercise of that or any other right, power or remedy.

17.   AMENDMENT

      This Deed may be amended only by another deed executed by all parties.

EXECUTED and DELIVERED as a deed.

JAMES HARDIE INDUSTRIES          )
LIMITED                          )
                                 )
__________________________________        ______________________________________
Signature                                 Signature

__________________________________        ______________________________________
Name                                      Name

__________________________________        ______________________________________
Director                                  Secretary
SIGNED SEALED and DELIVERED      )
by                               )
in the presence of:              )        ______________________________________
                                          Signature

__________________________________        ______________________________________
Witness                                   Name

__________________________________
Print name

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