Printing Tenders

Details: Description The Procuring Entity: Lgu-inopacan, Leyte Project Reference Number: 5%ldrrmf-100-200-25-01-038 Name Of Project: Purchase Of Medical Supplies For Drrm Office Operation Use Location Of Project: Poblacion, Inopacan, Leyte Standard Form Number: Sf-good-60 Standard Form Title: Request For Quotation Company Name: Address: Please Quote Your Price On The Item/s Listed Below, Subject To The General Conditions On The Last Page, Stating The Shortest Time Of Delivery And Submit Your Quotation Duly Signed By Your Representative Not Later Than 7 Calendar Days Upon Receipt In The Return Envelope Attached Herewith. (sgd) Francis Jonathan B. Phua Procurement Officer Note: 1. All Entries Must Be Typewritten. 2. Delivery Period Within 7 Calendar Days. 3. Warranty Shall Be For A Period Of One (1) Year For Equipment From The Date Of Acceptance By The Procuring Entity. 4. Price Validity Shall Be For A Period Of 30 Calendar Days. 5. G-eps Registration Certificate Shall Be Attached Upon Submission Of The Quotation. 6. Bidders Shall Submit Original Brochures Showing Certifications Of The Product Being Offered. Item Description: Quantity/unit 1. Oxygen Mask (adult) – 20 Pcs 2. Nasal Canula (adult) – 20 Pcs 3. Cotton Balls Jumbo – 20 Packs 4. Alcohol 70% Solution – 10 Gal 5. Face Mask (blue) – 15 Box 6. Nitrile Gloves (non-sterile) – 15 Box 7. Triangular Bandage – 102 Pcs 8. Disinfectant Spray 170g – 5 Bot 9. Multi-insect Killer 600ml – 8 Bot 11. Oxygen Regulator – 8 Pcs 11. Pulse Oxymeter W/ Battery – 5 Pcs 12. Emergency Blanket – 50 Pcs 13. Padded Board Splint – 5 Pcs 14. Cervical Neck Collar (child/adult) – 6 Pcs Delivery Period: 7 Days Warranty: Price Validity: 30 Calendar Days Name Of Procuring Entity: Lgu-inopacan, Leyte Project Reference Number: 5%ldrrmf-100-200-25-01-038 Name Of Project: Purchase Of Medical Supplies For Drrm Office Operation Use After Having Carefully Read And Accepted Your General Conditions, I/we Quote You On The Items At The Items At The Prices Noted Above. _______________________ Printed Name/signature _______________________ Tel. No./cellphone No./e-mail Address

Details: Amend 0004 Extends The Proposal Due Date. The Contractor Shall Furnish, Install, And Operate Utility-grade, Electric Power Generation Modules, Fuel Excluded. The Modules Shall Be Capable Of Supplying The Entire Base Peak Demand Of 6500 Kilo-volt-amperes (kva) At .8 Power Factor (pf) Continuously. The Power Generation Modules Shall Be Housed In Iso-listed, Modified Shipping Containers. The Units Shall Be Completely Self-contained (with The Exception Of The External Fuel Supply) And Shall Be Supplied With All The Necessary Electrical Controls And Switchgear So As To Operate In Parallel. It Is Anticipated That A Firm Fixed Price (ffp) Contract Will Be Awarded For A Total Of Five (5) Years, One Base Year And Four (4) One Year Option Periods. The Work Consists Of Supplying And Supporting All Generator Set Activities For Prime Power Operations In Support Of Asa Soto Cano, Honduras. Power Generation And Distribution Activities Are Defined As Preparation, Transport, Installation, Preventive Maintenance, Scheduled Maintenance, Emergency Maintenance, Service, Maintenance Of Associated Fuel Systems, Oil Water Separator And All Distribution System Maintenance Including The Underground And Overhead Systems Within The Switchyard. In Addition, The Contractor Shall Be Responsible For The Operations And Maintenance Of All Installed Primary Distribution From The High Side Of The Transformers, All Switchyard Primary, Pole Top Switches, Primary Metering Units Including Voltage Transformers (vt) And Current Transformers (ct), Primary Metal-clad Switchgear Assembly, And The Overhead Primary Ahead Of The Four Reclosers, Including The Reclosers Themselves And All Their Associated Parts, Located Outside Of The Switchyard Fence. The Work Also Consists Of The Operation, Monitoring, And Maintenance Of An Existing Government Owned 2-megawatt (mw) Photovoltaic (pv) Farm. The Pv Farm Operates In Parallel With The Generators As A Fuel Saving/peak Shaving Measure. This Procurement Is Unrestricted. The Naics Code Applicable To This Requirement Is 221112, The Size Standard For Which Is A Concern, Including Its Affiliates, Who Number Of Employees Does Not Exceed 950.the Solicitation Will Only Be Issued As A Direct Download At The Following Website: Https://piee.eb.mil. All Offerors Must Be Registered In The Procurement Integrated Enterprise Environment (piee) Before They Will Be Allowed To Download Solicitation Information. The Solicitation Will Not Be Provided In A Printed Paper Format; However, The Government Reserves The Right To Revert To Paper Medium When It Is Determined To Be In The Government?s Best Interest. Therefore, It Is The Responsibility Of The Offeror To Check The Website For Solicitation Posting And Any Changes To This Solicitation. Those Registering Are Responsible For The Accuracy Of The Information Provided.

Details: Description Request For Quotation Date: _________________________ Quotation No. Rfq 2025-12 Company Name : __________________________ Address : __________________________ Please Quote Your Lowest Price On The Item/s Listed Below, Subject To The General Conditions On The Last Page, Stating The Shortest Time Of Delivery And Submit Your Quotation Duly Signed By Your Representative Not Later Than The Closing Date. Engineering Office End User Note: 1. All Entries Must Be Typewritten 2. Delivery Period Within ____________________ Calendar Days 3. Warranty Shall Be For A Period Of Six (6) Months For Suppliers & Materials, One (1) Year For Equipment, From Date Of Acceptance By The Procuring Entity 4. Price Validity Shall Be For A Period Of __________________________calendar Days 5. Phil-geps Registration Number ________________________________ 6. Bidders Shall Submit Original Brochures Showing Certification Of The Product Being Offered 7. Approved Budget For The Contract (abc) P 113,440.00 Item No. Item Description Qty. Unit Unit Price Total Price 1 1/4 X 4 X 8 Hardiflex 33 Pcs 2 0.70mm X 5.0m Carrying Furring 28 Pcs 3 0.50mm X 5.0m Double Furring 62 Pcs 4 Wall Clip 50 Pcs 5 0.40mm X 2.40m Wall Angle 15 Pcs 6 Blind Rivet 1 Box 7 Flat Latex 8 Tins 8 Gloss Latex 7 Tins 9 Flat Wall Enamel 3 Gals 10 Quick Dry Enamel 3 Gals 11 Tinting Color (latex) 1 Ltr 12 Tinting Color (oil) 1 Ltr 13 Masonry Putty 2 Gals 14 Glazing Putty 2 Gals 15 Sand Paper 50 Pcs 16 Paint Thinner 1 Gal 17 Roller Brush 2 Pcs 18 Paint Brush 2 Pcs 19 Water Closet 1 Set 20 0.90m X 2.10m Panel Door W/ Doorjamb,d.knob And Hinges 1 Set 21 0.80m X 2.10m Flush Door W/ Door Jamb,d.knob And Hinges 1 Set Brand And Model: ______________________________ Delivery Period : _______________________________ Warranty : __________________________________ Price Validity : _________________________________ After Having Carefully Read And Accepted Your General Conditions, I/we Quote You On The Item At Prices Noted Above. __________________________________ Printed Name Signature __________________________________

Details: Description 1.00 General Requirements 1.01 Mobilization/delivery Of Materials 1.02 Project Billboard Sub-total 1.00 2.00 Flyover Finishes 2.10 Elevation 2.11 Thematic Textured Paint Finish With Epoxy Primer On Existing Steel Beams/girder (exterior Side) 2.12 Adobe Stone Vener Cladding 2.13 Built-up Brass Plated Metal Frame And Signage In Aluminum Backing (malolos Signage) 2.14 Entry Vehicle Clearance Arch (built-up Metal Gateway Arch In Epoxy Primer/automotive Paint Finish Complete With Signage And Built-up Metal Post (as Per Plan) 2.15 Gfrc Panel, Moldings, Frame, Delivery And Installation (painted) 2.16 Repair And Re-painting Of Flyover Railings 2.17 Galvanized Lace Iron Grille Work In Epoxy Primer/ Matte Black Automotive Paint Finish 2.18 Singkaban Deco Patterned Built-up Cat Iron Accent In Epoxy Primer/textured Paint Finish 2.19 Pre-cast Moulding In Thematic Marble Paint Finish 2.20 Rustic Brick Venner Cladding 2.20 Park 2.21 Stampcrete Cobble Stone Patterned With Rubberized Paint Coating 2.22 19mm Cement Iron-skid Print Patterned (polygonal) Floor Tile 2.23 Cement Finish Concrete Gutter In Matte Stone Sealer 2.24 200m Textured Dark Gray Paver Tiles 2.25 19mm Thk.non-skid Rubber Botton Tiles 2.26 300x300mm Non-skid Rubber Botton Tiles 2.27 10mm Stainless Steel Inserts On Concrete Ramp Gradient Spaced @ 10mm 2.28 Seat 1 Structure (7330x2095mm) Complete With Finishes 2.29 Seat 2 Structure (4700x3130mm) Complete With Finishes 2.30 Seat 2 Structure (4700x3130mm) Complete With Finishes 2.31 Seat 3 Structure (3750mm Dia,) Complete With Finishes 2.32 Planter Boxes Structure/softscape (complete With Turf Grass/plants) Sub-total 2.00 3.00 Electrical Works 3.01 Lighting Works 3.02 Bollards 3.03 Led Warm White Weatherproof Strip Covelight Subtotal 3.00 Total Direct Cost A. Ocm B. Profit C. Taxes Total Estimated Cost Say

Details: Description Philippine Science High School – Central Luzon Campus (pshs-clc) Wishes To Invite Proponent For The Supply And Delivery, Installation, Training To End-user, And Initial Calibration Of New Drying Oven With Abc Of Ninety-eight Thousand Pesos In Words And Php 98,000.00 In Figures. Reference No: Pr No. 2025-01-002-06 Item Description: Supply And Delivery, Installation, Training To End-user, And Initial Calibration Of New Drying Oven Qty: 1 Lot Abc: ₱98,000.00 Details: Inclusions Of Service To Be Rendered: -delivery Of New Drying Oven -installation Of New Drying Oven -training To End User/s With Certificate -initial Calibration With Certificate (and Sticker If Possible) Specification Of Drying Oven: -with Lcd Display For Calibration Functions And Temperature (display And Alarm In Case Excessive Temperature); With A Usb Port For Printer -stainless Steel Inside/inner Tank, High Quality With 4-corner Design With A Built-in Fan To Properly Circulate Circuit And To Balanced The Average Temperature In The Room Location (forced Convection Method) -intact With A Built-in Window Where Samples Can Be Viewed From The Outside And 3 Removable Shelves -power And Consumption: 100-245v, 50/60hz And 1545w -capacity: 138-140l -temperature: Range = Min. 9-10c To Max Of 300-310c; Resolution = Of 0.1c; Functuation Of (±)1c, (±)2.5c Uniformity Maximum Temperature -dimensions: Minimum Of 555mm X 453mm X 555mm, 77-80kgs Gross Weight And 60-65kgs Net Weight -time Range: 0-9999min/h Or 0-10000min/h Proponent Must Be Familiar With Cdc Regulations And Policies Proponent Must Be Familiar With Government Transactions Proponent Must Deliver The Items Within (30) Thirty Calendar Days Upon Receipt Of Purchase Order For More Information, Please Contact The Bids And Awards Committee Of Pshs-clc: Tel No. (045) 499-0136 / (045) 499-5597 Local 101 Or Email Us At Rfq@clc.pshs.edu.ph Submissions Will Be Accepted Until January 30, 2025, 9:00am At The Pshs- Clc, Lily Hill St., Clark Freeport Zone, Pampanga Or Through Email At Rfq@clc.pshs.edu.ph Jarvik Jason B. Rogacion Administrative Officer V/procurement Officer Philippine Science High School – Central Luzon Campus Telephone No. (045) 499 0136; (045) 499 5597 Local 101 Email: Rfq@clc.pshs.edu.ph

Details: Rfq Type Goods Goods Corporate Merchandise Reference Number Gl12500467 Title Supply And Delivery Of Posters Description 13 Each X Supply And Delivery Of Posters Specification* Please Note That Physical Samples Will Be Requested A0 Posters Self Adhesive Vinyl 1 X Copy Each Of The 13 Print-ready Pages Attached Contact Person Zukiswa Mbatani Contact No. 072 180 7146 E-mail Address Zukiswa.mbatani@capetown.gov.za Deliver Address 73 Hertzog Boulevard, Cape Town Nb!! Preferred Supplier To Sumbit Final Product For Approval To Communication Department For Final Approval. Samples Shall Be Supplied By A Bidder At His/her Own Expense And Risk. The City Shall Not Be Obliged To Pay For Such Samples Or Compensate For The Loss Thereof, Unless Otherwise Specified In The Bid Documents. The City Reserves The Right To Keep Samples Supplied By The Appointed Bidder. Unsuccessful Bidders Can Collect Their Samples Within 90 Days After The Final Notification Of Award Has Been Send To Suppliers, After Which The City Has The Right Not To Return Such Samples And To Dispose Of Them At Its Own Discretion. Please Note That After Closing Date Of Rfq It Will Be Request For Suppliers To Supplier To Submitt Actual Samples With In 3 To 4 Days. Delivery Date2025/02/28 Delivery Toinformation Tech And Telecom Maintenance Planning Plant Delivery Address73 Hertzog Boulevard, Cape Town Contact Personzukiswa Mbatani Telephone Number0721807146 Cell Number Closing Date2025/02/03 Closing Time04 00 Pm Rfq Submission Fax0000000000 Rfq Submission Fax 2 Buyer Email Addressgl1.quotations@capetown.gov.za Buyer Detailsc.williams Buyer Phone0214001789 Attachments No Attachments Note On 1 August 2018 The City Of Cape Town Went Live With E-procurement Which Was Piloted With 3 Commodities Clothing, Building Hardware And Is&t. No Manual Submissions Will Be Accepted For These Commodities And Suppliers Must Log In To E-services Portal To Access Rfqs. Bids Must Be Compliant With The Preferential Procurement Regulations, 2017 Including But Not Limited To Local Content, Functionality, Price And Preference, Eligibility Criteria And Relevant Statutory Criteria. The Details Of This Are Contained In The Rfq Document And/or The Specification Advertised Via E-procurement. Only Locally Produced Goods Or Locally Manufactured Goods, Meeting The Stipulated Minimum Threshold For Local Production And Content, Will Be Considered, Where Applicable.

Details: Description Date: January 20,2025 Project Reference No: 25-01-0045 Quotation No. _________ Name Of Project: Procurement Of Various Spare Parts For The Repair & Maintenance Of Mitsubishi Strada Saa-6292, Alaminos City Location Of The Project: Alaminos City, Pangasinan Request For Quotation Dear Please Quote Your Lowest Price On The Item/s Listed Below, Subject To The General Conditions At The Dorsal Of This Rfq, Stating The Shortest Time Of Delivery And Submit Your Quotation Duly Signed By Your Representative Not Later Than January 27, 2025 At The Bids And Awards Committee Secretariat, 2nd Floor,bac Office, Alaminos City, Pangasinan. Open Quotations May Be Submitted, Manually Or Through Facsimile Or Email At The Address And Contact Numbers Indicated Below. Rowena F. Ruiz Bac Chairperson Special Instructions - (please Read Carefully) Note: 1. All Entries Must Be Typewritten 2. Delivery Period Within 10 Calendar Days 3. Warranty Shall Be For A Period Of Six (6) Months For Supplies & Materials, One (1) Year For Equipment, From Date Of Acceptance By Procuring Entity 4. Price Validity Shall Be For A Period Of 30 Calendar Days 5. Bidders Must Have Logged-in At Philgeps. (proof Of Log-in Must Be Attached) 6. Phil-geps Registration Number ______________________ 7. Bidders Shall Submit Original Brochures Showing Certifications Of The Product Being Offered. 8. Approved Budget For Contract (abc) Php 85,878.00 Item No. Unit Item & Description Qty Unit Price Total Amount Set Idler Tensioner Bearing ( Big & Small) 1.00 - Set Bearing 1.00 Set Drive Belt Tensioner 1.00 Set Tensioner Adjuster 1.00 Set Rocker Arm 1.00 Pcs Valve Cup 2.00 Pc Rocker Arm Bolt 3.00 Pc Drive Belt 1.00 Pc Timing Belt Cover (lower) 1.00 Set Overhauling Basket 1.00 Set Timing Belt 1.00 - Total: - Brand And Model : Delivery Period : Warranty : After Having Carefully Read And Accepted Your General Conditions, I/we Qoute You On The Item At Prices Noted Above. Quoted By: - Printed Name/signature Tel. No. / Cellphone No. E-mail Address Date

Details: Description Republic Of The Philippines Film Development Council Of The Philippines 7/f. Mirax Tower 2270 Chino Roces Ave. Ext., Makati City Tel: (02) 8251-7493 Loc. 120 Film Development Council Of The Philippines Request For Quotation Office/ End-user: Afd - Procurement Unit Date: January 21, 2025 Company Name: Film Development Council Of The Philippines P.r. No.: Address: 7/f. Mirax Tower 2270 Chino Roces Ave. Ext., Makati City Tel. No./fa No.: (02) 8251-7493 Loc. 120 Tin No.: 226-381-796-000 Please Quote Your Lowest Price On The Item(s) Listed Below, Subject To The General Conditions Stated Below And Submit Your Quotation Duly Signed By Your Representative. Please Submit The Filled-up Form On Or Before 27 January 2025, 9:00 Am To Procurement@fdcp.gov.ph General Conditions: 1. Delivery Period Within Dates Indicated In The Purchase Order Form. Administrative Penalties To Sec. 69 Of The Revised Irr-ra 1984 Shall Be Imposed For Non-delivery Without Valid Reason. 2. Warranty Shall Be For A Minimum Of Three (3) Months For Supplies & Materials; One Year For Equipment From Date Of Acceptance By The End-user. 3. Price Validity Shall Be For A Period Of Sixty (60) Calendar Days. Regina Fernandez 4. Philgeps Registration Certificate/mayor's Permit/dti/bank Name/account/branch Shall Be Attached Upon Submission Of The Quotation. Assistant Bac Secretariat 5. Bidders Shall Submit Original Brochures Showing Certification Of The Product, If Applicable. 6. Please Indicate The Brand For Each Items Being Offered. 7. The Approved Budget Ceiling For This Procurement Is Php 560,000.00 Unit Item & Description Quantity Unit Price Total Roundtrip Flight To Berlin Pax Manila - Berlin - Manila 4 Manila To Berlin February 13, 2025 Berlin To Manila February 20, 2025 Note: Refundable And Rebookable Flight With Check-in Baggage Allowance ***nothing Follows*** Total: Source Of Fund: Warranty: Delivery Period: Price Validity: After Having Carefully Need & Accepted Your General Conditions, We Quote You On The Item(s) At Prices Note Above. If The Space Of Provided On The Delivery Period, Warranty & Price Validity Are Left Blank, It Means That I Concur W/ The Terms & Conditions Specified By Fdcp Procurement Unit. _______________________ Printed Name/signature/date Name Of Company: Address: Name Of Representative: Tin: Email: Contact No.:

Details: Description Tesda-op-as-04-f03 Rev. No. 00 – 03/01/17 Annex "a" Technical Education And Skills Development Authority Provincial Training Center – Boac, Marinduque 2nd Flr. Public Market, Market Site, Mogpog, Marinduque 4901 Email: Ptc.marinduque@tesda.gov.ph Contact Number: 0907 – 432 – 5246/(042) 754 – 3980 Price Quotation Form Date: Erdie L. Mistal Bac Chairperson Ptc-marinduque Sir/madam: After Having Carefully Read And Accepted The Terms And Conditions In The Request For Quotation, Hereunder Is Our Quotation/s For The Item/s As Follows: Item No. Item Description Qty Unit Approved Budget For The Contract (in Peso) Offer Compliance With The Technical Specifications (please Check) Remarks (price/others) Unit Price Yes No 1 Automotive Wire # 12 ( 30 M),assorted Colors 4 Pcs. [ ] [ ] 2 Clutch Disc 1 Pc [ ] [ ] 3 Pressure Plate 1 Pc [ ] [ ] 4 Brake Shoe 2 Pc [ ] [ ] 5 Brake Pads 2 Pc [ ] [ ] 6 Alternator Belt For 2e Engine 1 Pc [ ] [ ] 7 Apron ( Maong) 15 Pcs. [ ] [ ] 8 Safety Gloves 15 Pcs. [ ] [ ] 9 Safety Goggles 15 Pcs. [ ] [ ] 10 A4 Bond Paper 10 Box [ ] [ ] 11 Manual Transmission Gear Oil Sae: 75w-90 1 Liter 10 Liters [ ] [ ] 12 Electrical Tape(big) 10 Pcs. [ ] [ ] 13 Air Freshener 30 G 10 Can [ ] [ ] 14 Automotive Fuse 2 Set [ ] [ ] 15 (c-110) Vic Oil Filter C110 5 Pcs. [ ] [ ] 16 Spark Plug Toyota Corolla 2e 8 Pcs. [ ] [ ] 17 Brake Fluid( Dot 3) 10 Liters [ ] [ ] 18 Car Wash Shampoo 10 Liters [ ] [ ] 19 Gasoline 200 Liters [ ] [ ] 20 Super Long Life Coolant 2 Liters (pink) 10 Pcs. [ ] [ ] 21 Engine Oil Fully Synthetic Sae 5w - 40w 4 Gal. [ ] [ ] 22 1/2" Dia. G.i Pipe, Sched.40 5 Pcs. [ ] [ ] 23 3/4" Dia. G.i Pipe, Sched.40 3 Pcs. [ ] [ ] 24 Carburator 2e Engine 1 Set [ ] [ ] 25 Balljoint, Left &right 2 Pcs. [ ] [ ] 26 Rack And Pinion,left &right 2 Pcs. [ ] [ ] -nothing Follows- [ ] [ ] Name Of Business/company Signature Over Printed Name Office Telephone/fax. No. Mobile No. Email Address

Details: Description Republic Of The Philippines Department Of Health Bicol Center For Health Development January 20, 2025 The Manager __________________________ __________________________ __________________________ Dear Sir/madam: Please Quote Your Lowest Price On The Item/s Listed Below Subject To The General Conditions Stated Below. Definitely, No Cod Payments Shall Be Allowed. Filled Canvass Form Should Be Returned To This Office In A Sealed Envelope. __________________________________________________ Rosa Maria B. Rempillo, Md, Mchm Cese Bac Chairperson Qty. Unit Item & Description Total Abc Unit Cost Total Cost 1 Lot Events Management For The Conduct Of The Major Health Promotion Campaign: Bicol Oral Health Summit On February 11, 2025 In A Covered Court In Sorsogon 450,000.00 P ___________ P ___________ Terms Of Reference (see Attached Tor) . Banners Certificates Plaques Functional Billboard Lights And Sounds Photo And Video Documentation Stage Set-up Leis Performers Led Wall Coffee Table Book Materials For Posting And Set Up Events Management Fee Tokens Total: 450,000.00 P ___________ Subject To The Following Conditions: 1. Subject To Witholding Tax 2. Subject To 5% Retention For Warranty 3. Quotation Exceeding The Approved Budget For The Contract (abc) Php 450,000.00 Shall Not Be Considered For Award. 4. Philgeps Registration Is Required (to Register Log On To Www.philgeps.net) Philgeps Registration No.:______________ (if Applicable) 5. New Suppliers Must Submit The Following Legal, Technical And Eligibility Documents To Be Eligible To Participate In This Procurement Process; (a) Sec/dti Registration Certificate; (c) Philgeps Registration; (e ) Latest Income & Business Tax Return (b) Mayor's Permit/license; (d) Omnibus Sworn Statement (for Above 50k) 6. Any Interlineations, Erasures Or Overwriting Shall Be Valid Only If They Are Signed Or Initialled By The Bidder Or His/her Authorized Representative. 7. Submission Of Quotation Is At The Procurement Office, Doh Bicol-chd, Legazpi City. Open Submission May Be Submitted Through Email Address: Canvass @bicol.doh.gov.ph Deadline Of Submission Will Be On: ____________________ @ 9:00am Pr No. 25-01-092 (hpcc) After Having Carefully Read And Accepted Your General Conditions, I/we Quote You On The Item At Prices Noted Above. _______________________________________ Name Of Establishment & Telephone No. _______________________________________ Downloaded Thru Doh Bicol Chd Website & Philgeps Signature Over Printed Name Of Manager/ Authorized Representative _______________________________________ Complete Mailing Address _______________________________________ Complete Email Address (pls Write Legibly)