BLUE RIBBON NETWORK AGREEMENT

Effective Date
Network Member Name
Network Member’s
Principal Place of Business

This Blue Ribbon Network Agreement (“Agreement”) is made and entered into as of the Effective Date set forth above by and
between Blue Ribbon Network LLC, a Texas limited liability corporation, with its principal place of business at 7020 Portwest Drive, Suite
150, Houston, Texas 77024 (“Blue Ribbon”) and the Network Member specified above (herein referred to as “Contractor”).

WHEREAS, Blue Ribbon or its affiliate, Blue Ribbon Legal LLC (“BR Legal’), has certain valuable “Customer Contacts,” marketing
opportunities, and administrative efficiencies;

WHEREAS, the Customer Contacts of Blue Ribbon are of value to Contractor;

WHEREAS, it is of mutual value for Blue Ribbon and for its Customer Contacts to work with Contractor so that Contractor may provide
certain services, products, and goods (“Services/Goods/Products”), as needed and required by Blue Ribbon and/or its Customer Contacts, to
those Customer Contacts;WHEREAS, it is likewise of value for Contractor to work with Blue Ribbon and its Customer Contacts to provide
those Services/Goods/Products, as needed and as requested by Blue Ribbon and/or its Customer Contacts;

WHEREAS, the parties further envision that, as a result of the Blue Ribbon Network, Contractor may also enjoy further value from
relationships that may be developed with other Blue Ribbon Network Members (other Contractors who have or will join the Blue Ribbon
Network, as Contractor has);

WHEREAS, Contractor and other Network Members may provide opportunities for additional work among the Network Members on either a
subcontract or referral basis;

WHEREAS, in light of the value envisioned by both Blue Ribbon and Contractor, the parties seek to enter into an Agreement so that (1) Blue
Ribbon may have the opportunity (though not the requirement) either to contract with Contractor for the provision of
Services/Goods/Products to the Blue Ribbon Customer Contracts; or (2) Blue Ribbon, if it chooses, may refer work to Contractor, in return
for certain referral fee(s), so that Contractor may work directly with the Blue Ribbon Customer Contact(s); and so that (3) the Contractor, if it
chooses, may take advantage of other marketing and work opportunities, if any arise, through its relationships with other Blue Ribbon
Network Members;

NOW THEREFORE, in light of the mutual value seen in this arrangement by Blue Ribbon and Contractor, they agree as follows:

1. Overview of the Work and Term
a. Work from Blue Ribbon to Contractor. From time to
time during the Term, defined 1(c), Blue Ribbon may request
Contractor to perform or provide certain
Services/Goods/Products as part of contracts that Blue Ribbon
has with its Customer contracts (“the Subcontractor Work”). In
addition, Blue Ribbon may refer certain work, projects or
contracts to Contractor so that Contractor may perform or provide
Services/Goods/Products directly to Blue Ribbon Customer
Contacts (“the Referral Projects”). Blue Ribbon has no obligation
to request Contractor to perform or provide any such
Services/Goods/Products, as Subcontractor Work, nor is there
any obligation for Blue Ribbon to refer any such work or projects
to Contractor, as Referral Projects. Further, if Blue Ribbon
requests Contractor to perform or provide Subcontractor Work or
offers Contractor Referral Projects, Contractor has no obligation
to agree to perform or provide any such
Services/Goods/Products. Any request by Blue Ribbon to have
Contractor perform or provide Subcontractor Work or Referral
Project pursuant to this Agreement will be set forth in writing in a
document titled “Statement of Work,” example attached as
Exhibit A. Every Statement of Work shall be governed by the
pertinent portions of this Agreement. For each Subcontractor
Work, a Statement of Work will specify the
Services/Goods/Products to be performed or provided by
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Contractor, including the specific results to be achieved (if
applicable), the start date and the required completion date for
the services, or the required delivery date for goods or products,
and will become effective only when executed by both parties.
For each Referral Project, the Statement of Work shall provide
the Contractor sufficient knowledge of the work, service or good
to be provided, along with sufficient contact information for the
Customer Contact, so that Contractor may negotiate the
Services/Goods/Products contract on its own, if it chooses and is
possible. Provision of a Statement of Work for a Referral Project
is not a guarantee that Contractor will obtain any such work from
the Customer Contact, as it is up to the Contractor to follow up on
any such referral and negotiate (or not) a contract with the
Customer Contact. Payment for these services is specified in
Section 3, and the parties understand that Contractor shall pay a
fee to Blue Ribbon for all work that follows from any Customer
Contact for whom Contractor works at any time, when Contractor
is a part of the Blue Ribbon Network. The fees specified below
(Section 3) are in recognition for the services and opportunities
Blue Ribbon Network provides to Network Members, which they
would not have but for being part of the Blue Ribbon Network
b. Work among Network Members. Similar to that
anticipated work from Blue Ribbon to Contractor (see 1 (a)
above), from time to time during the Term, defined 1(c), Network
Members (or other contractors to Blue Ribbon like Contractor)
may request that Contractor (or vice versa) perform or provide
certain Services/Goods/Products, either in a subcontractor role or
in a referral role. There is no requirement that either the Network
Members or the Contractor offer such opportunities to each other
or agree to any such offers from Network Members.
Nonetheless, Contractor understands that, as a part of any such
work, it shall be responsible for payment to Blue Ribbon of a fee,
as specified below (Section 3), in recognition of the services and
opportunities it provides to Network Members, which they would
not have but for being part of the Blue Ribbon Network.
c. Term. The “Term” will commence on the Effective Date
and will continue for one (1) year, unless earlier terminated
pursuant to the provisions of Section 7, and will automatically
renew for successive one year periods, unless either party
provides written notice of its intent not to renew the Agreement at
least sixty (60) days prior to the end of the then-current period.
d. Changes in Subcontractor Work. In regard to any
Subcontractor Work, if Blue Ribbon wishes to change any
provisions of a Statement of Work, then Contractor will review the
proposed change and determine the feasibility of the change and
any effect it will have on the cost and schedule as set forth in the
Statement of Work. If agreed, both parties will amend the
Statement of Work accordingly.
e. Relationship Manager. If a given project warrants such
communication, Blue Ribbon will designate a “Relationship
Manager” or principal Blue Ribbon representative for the
Contractor to discuss any Subcontractor Work. In that instance,
the Contractor shall also designate an appropriate Relationship
Manager. For any such Subcontractor Work, Contractor shall
attend meetings at reasonable times as requested by Blue
Ribbon, if any are requested.
f. Review by Blue Ribbon. As deemed necessary for any
Subcontractor Work, Blue Ribbon may review the progress of
Contractor’s performance or provision of the
Services/Goods/Products at Contractor’s or Customer’s facilities.
Contractor will cooperate with Blue Ribbon in performing such
reviews, including, without limitation, providing Blue Ribbon with
access to all work in progress, documents and other materials,
as reasonably requested by Blue Ribbon. Blue Ribbon may
perform any such reviews only during normal business hours by
providing Contractor with reasonable advance written notice. In
performing such reviews, Blue Ribbon will not interfere unduly
with the operation of Contractor’s other business activities, and
Blue Ribbon will comply with Contractor’s reasonable safety,
security and other policies and procedures.
g. Notification to Blue Ribbon - Referral Projects. If
Contractor is able to secure an agreement to provide or perform
any Services/Goods/Products for a Customer Contact referred by
Blue Ribbon, then Contractor shall within ten (10) days of
acceptance of such contractual obligation provide Blue Ribbon
with a description of any such agreement (including a copy of
that agreement) and a list of the Services/Goods/Products to be
provided. This notification requirement applies to all work
obtained at any time from any Customer Contact referred by Blue
Ribbon, when Contractor is a part of the Blue Ribbon Network.
For example, if, after an initial referral of work, Contractor is
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asked by a Customer Contact to do some other or different work
(than that originally referred to Contractor), then Contractor shall
notify Blue Ribbon, per the procedure in this paragraph, and shall
pay a fee, as specified below (Section 3), to Blue Ribbon. The
provision of this information by Contractor to Blue Ribbon shall
be made solely to assist in determining and monitoring the
required referral fees that Contractor agrees to pay to Blue
Ribbon as a result of any Referral Project (see Section 3). Blue
Ribbon does not and shall not control or monitor, and it is not
responsible for, any such Referral Project.
h. Notification to Blue Ribbon – Network Member Work.
To the extent that any Network Member refers or subcontracts
work to Contractor (or vice versa), see 1(b) above, generally
referred to as “Network Member Work,” then Contractor shall
notify Blue Ribbon in the method described in 1(g) above. The
provision of this information by Contractor to Blue Ribbon shall
be made solely to assist in determining and monitoring the
required referral fees that Contractor agrees to pay to Blue
Ribbon as a result of the Network Member Work (see Section 3).
Blue Ribbon does not and shall not control or monitor or be
responsible for any such Network Member Work.
2. Relationship of Parties.
a. Independent Contractor Relationship. Whether in
connection with Referral Projects, Subcontractor Work, or the
Network Member Work, Contractor is an independent contractor
of Blue Ribbon and is not a partner, joint venturer, agent or
employee of, and has no authority to bind, Blue Ribbon by
contract or otherwise. In regard to Subcontractor Work,
Contractor will perform or provide the Services/Goods/Products
under the general direction of Blue Ribbon, as a primary
contractor to the Customer Contact. However, in regard to
Subcontractor Work, Referral Work and Network Member Work,
Contractor will determine, in Contractor’s sole discretion, the
manner and means by which the Services/Goods/Products are
accomplished or provided, as the case may be, subject to the
requirement that Contractor shall at all times comply with
applicable law. Blue Ribbon has no right or authority to control
the manner or means by which the Services/Goods/Products are
done, provided or completed.
b. Independent Tax Liability. Contractor will report as
income all compensation received by Contractor pursuant to this
Agreement to the appropriate taxing authorities. Contractor will
indemnify Blue Ribbon and hold it harmless from and against all
claims, damages, losses and expenses, including reasonable
fees and expenses of attorneys and other professionals, relating
to any obligation imposed by law on Blue Ribbon to pay any
withholding taxes, social security, unemployment or disability
insurance, or similar items in connection with compensation
received by Contractor pursuant to this Agreement. Contractor
will not be entitled to participate in any plans, arrangements, or
distributions by Blue Ribbon pertaining to any bonus, stock
option, profit sharing, insurance or similar benefits for Blue
Ribbon’s employees.
c. Insurance Requirements. Contractor will maintain
adequate insurance to protect Contractor from the following: (i)
claims under workers’ compensation and state disability acts; (ii)
claims for damages because of bodily injury, sickness, disease or
death that arise out of any negligent act or omission of Contractor
or its employees; and (iii) claims for damages because of injury
to or destruction of tangible or intangible property, including loss
of use resulting therefrom, that arise out of any negligent act or
omission of Contractor or its employees.
3. Invoicing and Payment
a. Subcontractor Work from Blue Ribbon. Subject to the
terms and conditions of this Agreement, for the performance of
the Services/Goods/Products set forth in an executed Statement
of Work, Blue Ribbon will pay Contractor the fees agreed upon in
the Statement of Work. Contractor will invoice Blue Ribbon on a
monthly basis. Blue Ribbon will pay each properly submitted
invoice no later than sixty (60) days after its receipt.
b. Referral Projects from Blue Ribbon to Contractor.
Contractor shall pay to Blue Ribbon an amount equal to
__________ percent (__%) of the gross total invoice as
submitted to the referred Customer Contact, or, if the parties so
choose, any amount determined in the Statement of Work, if one
exists. Such payments shall be due within sixty (60) days of the
submission of such invoice to the referred Customer Contact.
Contractor shall deliver to Blue Ribbon a copy of each invoice (or
an appropriate and agreed-upon accounting summary) submitted
to each referred Customer Contact, at the same time each
invoice is sent to the Customer Contact. This process shall be
followed as to all work that Contractor may receive from the
Customer Contact at any time, as long as Contractor is a
Network Member (regardless of whether Blue Ribbon specifically
refers the work to Contractor or not).
c. Network Member Work. If Contractor refers work to another
Network Member, Contractor shall charge that other Network
Member a referral fee of _______ percent (__%) of the gross
total invoice submitted by the Network Member to the particular
customer, and Contractor shall split that fee with Blue Ribbon.
Contractor is obligated to obtain copies of all pertinent invoices
submitted by the Network Member to whom the work is referred.
If, alternatively, Contractor performs or provides
Services/Goods/Products as a Subcontractor to any other
Network Member, Contractor shall pay Blue Ribbon an amount
equal to __________________ percent (____ %) of the gross
total invoice as submitted to the Network Member. Such
payments shall be due as follows: (1) in the case of referral work,
within sixty (60) days of the Network Member’s submission of its
invoice to the particular customer; and (2) in the case of
subcontractor work, within sixty (60) days of the Contractor’s
submission of its invoice to the Network Member. This process
shall be followed as to all work that Contractor may receive from
or refer to any Network Member at any time, as long as
Contractor is a Network Member.
d. Records Access. Contractor agrees to provide Blue
Ribbon with reasonable access to its records to confirm any
information related Subcontractor Work, Referral Projects, and
Network Member Work, during normal business hours, upon
three (3) business day notice.
5. Confidentiality/Nonsolicitation
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a. Blue Ribbon Will Provide Confidential Data. Blue
Ribbon agrees to provide Contractor, and Contractor
acknowledges that it will acquire from Blue Ribbon, confidential
data, materials and information (“Confidential Data”). This
Confidential Data shall include all trade secret, marketing,
financial and other proprietary, non-public information and
materials ofBlue Ribbon or its customers, as well as knowledge
about the business, financial condition, products, programming
techniques, experimental work, customers and suppliers of Blue
Ribbon, its customers or licensors. All such Confidential
Information knowledge, information and materials acquired are
and will be the trade secrets and confidential and proprietary
information of Blue Ribbon, its customers or licensors.
Confidential Information will not include, however, any
information that (i) is or becomes generally known to the public
through no fault or breach of this Agreement by Contractor;
(ii)Contractor can demonstrate by written evidence was rightfully
in Contractor’s possession the time of disclosure, without an
obligation of confidentiality; (iii) Contractor can demonstrate by
written evidence was independently developed by Contractor
without use of or access to the Confidential Information; or (iv)
Contractor rightfully obtains from a third party without any duty of
confidentiality or restriction on use or disclosure.
b. Contractor Agrees to Keep the Data Confidential.
Contractor agrees to hold all such Confidential Information in
strict confidence, will use Confidential Information only for the
purpose of performing or providing the Services/Goods/Products,
and will limit disclosure of Confidential Information to its
employees that need to access such Confidential Information for
the foregoing permitted purpose and are subject to legally
binding obligations to maintain the confidentiality of the
Confidential Information that are at least as stringent as the
obligations under this Section. Contractor may disclose
Confidential Information to the extent required by applicable law
or order of a court, government agency or other government
body, but only if Contractor provides prompt notice of that
requirement to Blue Ribbon to enable Blue Ribbon to seek a
protective order or otherwise prevent or restrict the disclosure.
c. Nonsolicitation. Further, in return for the mutual
promises of the parties and in particular in return for Blue
Ribbon’s agreement to provide Confidential Data, Contractor
agrees for a period of twelve months not to solicit the customers
of Blue Ribbon, BR Legal, or of any other Network Member, of
which customer Contractor had any contact or knowledge, as a
result of being a Network Member (if known about during the a
one-year time period prior to the termination of this Agreement).
This nonsolicitation clause does not apply to customers listed by
Contractor prior to becoming a Network Member; upon signing
this Agreement, Contractor shall disclose to Blue Ribbon a list of
all its customers. Additionally, Contractor agrees not to solicit or
seek to hire any employees of Blue Ribbon or its Network
Members during the same twelve month time period. The parties
agree that this clause shall be reasonably interpreted under the
law, and that the time and geographical limitations shall be
reasonably restricted per the law, although the clause shall be
enforced nonetheless to provide Blue Ribbon and its Network
Members with the broadest protection legally possible. To the
extent any portion of this Nonsolicitation Clause is deemed overly
broad, the parties agree that it may be reformed by any court of
law or arbitrator, if applicable.
 d. The obligations and requirements under the
Confidentiality/Nonsolicitation clauses above shall survive the
termination of this Agreement and the end of the Contractor’s
affiliation as a Network Member.
6. Indemnification
a. Contractor will indemnify and hold harmless Blue
Ribbon from and against all claims, damages, losses, penalties,
punitive damages, attorneys fees, costs, and expenses, including
court costs and reasonable fees and expenses of attorneys,
expert witnesses, and other professionals, arising out of or
resulting from, and, at Blue Ribbon’s option, Contractor will
defend Blue Ribbon against, any action by any person (including
any Customer Contact) against Blue Ribbon that is related,
directly or indirectly, to any Services/Goods/Products performed
or provided under this Agreement. This indemnification and hold
harmless right includes for example, without limitation, (1) any
action by a Customer Contact or other third party against Blue
Ribbon that the Services/Goods/Products provided by Contractor
were defective or breached any duty to anyone (whether in strict
liability, tort or contract or whether based on any statute,
regulation, rule or ordinance) as may be owed under any local,
state or federal common law or statutory scheme; or (2) any
action based on any contractual breach or negligent act or
omission or grossly, willfully, malicious, or reckless conduct of
Contractor or its employees, solely or in part, which results in: (i)
any bodily injury, sickness, disease or death; (ii) any injury or
destruction to tangible or intangible property (including computer
programs and data); or (iii) in any other loss, damage or penalty
demanded.
b. Blue Ribbon will indemnify and hold harmless
Contractor from and against all claims, damages, losses and
expenses, including court costs and reasonable fees and
expenses of attorneys, expert witnesses, and other
professionals, arising out of or resulting from, and, at
Contractor’s option, Blue Ribbon will defend Contractor against:
(i) any action by a third party (including any Customer Contact)
against Contractor that is based solely on any claim that Blue
Ribbon breached a duty to anyone (whether in strict liability, tort
or contract or whether based on any statute, regulation, rule or
ordinance) as may be owed under any local, state or federal
common law or statutory scheme; or (2) any action based solely
on any contractual breach or negligent act or omission or grossly,
willfully, malicious, or reckless conduct of Blue Ribbon or its
employees which results in: (i) any bodily injury, sickness,
disease or death; (ii) any injury or destruction to tangible or
intangible property (including computer programs and data); or
(iii) in any other loss, damage or penalty demanded.
7. Termination and Expiration
a. Either party may terminate this Agreement with or
without cause with five (5) days’ prior written notice. Termination
of this Agreement will not terminate existing Statements of Work
unless specified by Blue Ribbon.
b. Termination by either party in accordance with this
Section 7 shall not be deemed an election of remedies, and all
other remedies provided by this Agreement or available at law or
in equity shall survive any termination.
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c. Upon the expiration or termination of this Agreement
for any reason, Contractor will promptly notify Blue Ribbon of all
Confidential Information, in Contractor’s possession or control
and, at Contractor’s expense and in accordance with Blue
Ribbon’s instructions, will promptly deliver to Blue Ribbon all
such Confidential Information.
d. The provisions of Sections 2(b), 3, 5, 6, 7(b), 7(c), 7(d),
8, 9(c) and 10 will survive the expiration or termination of this
Agreement.
8. Limitation of Liability
EXCEPT FOR THE INDEMNIFICATION OBLIGATIONS
SET FORTH IN SECTIONS 2(B) AND 6, EACH PARTY WILL
NOT BE LIABLE FOR ANY INDIRECT, CONSEQUENTIAL,
INCIDENTAL, PUNITIVE OR SPECIAL DAMAGES SUSTAINED
IN CONNECTION WITH OR ARISING OUT OF THIS
AGREEMENT, WHETHER BASED ON BREACH OF
CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT
LIABILITY, OR OTHERWISE, EVEN IF EITHER PARTY KNEW
OR SHOULD HAVE KNOWN OF THE POSSIBILITY OF SUCH
DAMAGES.
9. Warranties
a. Contractor will provide or perform the
Services/Goods/Products to Blue Ribbon and/or Customer in a
good and workmanlike manner in accordance with industry
standards.
b. Contractor represents and warrants that Contractor has
no pre-existing obligations or commitments that would hinder
Contractor’s performance of its obligations under this Agreement.
c. Because of the trade secret subject matter of each
party’s business, both Contractor and Blue Ribbon agree that
they will not solicit the services or employment of any of the
employees, suppliers or service providers of the other party
during the Term and for a period of twelve (12) months
thereafter.
10. General
a. Entire Agreement. This Agreement and each
Statement of Work executed by the parties, which are
incorporated into and made a part of this Agreement, constitutes
the entire agreement between the parties with regard to the
subject matter hereof and supersedes all prior oral and written
agreements, understandings, representations, proposals or
communications, of whatsoever kind, between the parties with
respect to the subject matter of this Agreement. If the terms of
this Agreement conflict with the terms of any Exhibit or executed
Statement of Work, then the terms of this Agreement will govern
and control to the extent of the conflict.b. All Changes
Must Be in Writing. No modifications or amendments to this
Agreement and no waiver of any provision of this Agreement will
be valid unless made in writing and signed by duly authorized
representatives of the parties hereto.
 c. No Assignment. Contractor may not assign
Contractor’s rights or delegate Contractor’s obligations under this
Agreement either in whole or in part without the prior written
consent of Blue Ribbon. Any attempted assignment or
delegation without such consent will be void.
d. Because the Services/Goods/Products are personal
and unique and because Contractor will have access to
Confidential Information, Blue Ribbon will have the right to
enforce this Agreement and any of its provisions in a court of law
by injunction, specific performance or other equitable relief,
without having to post a bond or other consideration, in addition
to all other remedies that Blue Ribbon may have for a breach of
this Agreement.
professional advisors, and to any actual or potential investors
subject to an obligation to keep it confidential.
j. The failure of either party, in one or more instances, to
insist upon the performance of any term or condition or to
exercise any right or remedy available to such party, will not be
construed as a waiver by such party of the right to insist upon the
performance or exercise of any right or remedy now available or
which may arise in the future.
k. The unenforceability of any provision hereof will not
affect the remaining provisions of this Agreement, but rather such
provision will be severed and the remainder of this Agreement
will remain in full force and effect.

e. Recovery of Attorneys Fees. If any action is necessary
to enforce the terms of this Agreement, the substantially
prevailing party will be entitled to reasonable attorneys’ fees,
costs and expenses in addition to any other relief to which such
prevailing party may be entitled.
f. Texas Law/Courts. This Agreement will be governed
by and construed in accordance with the laws of the State of
Texas, without reference to its conflicts of laws principles. Each
party will bring any legal actions or proceedings against the other
party relating to this Agreement or the Services/Goods/Products
in the state courts in Harris County, Texas, or the federal courts
in the Southern District of Texas, as is appropriate, and each
party hereby submits to personal jurisdiction and venue therein;
provided, however, that Blue Ribbon will at all times have the
right to commence proceedings in any other court of its choice of
appropriate jurisdiction to obtain relief for protection of intellectual
property rights.
l. This Agreement may be executed in any number of
counterpart copies, each of which will be deemed an original, but
which together will constitute a single instrument.
m. All paragraph headings and captions used herein are
for the convenience of the parties only and will not be part of the
text, or affect the meaning of this Agreement.
n Each of the parties hereto acknowledges to the other
that it has had the opportunity to have this agreement reviewed
by counsel of its choice and has had the opportunity to obtain the
assistance of such counsel in the negotiation, preparation,
execution and deliver thereof.

g. Jury Waiver. The parties waive their right to a jury trial

in connection with any and all claims, disputes, and controversies
between them, whether individual, joint or class in nature, arising
from this Agreement, any Statement of Work, or any Referral
Project. This clause applies to all other agreements that the
parties sign in relation to their relationship, and to all matters
dealing with that relationship, even if outside of the specific terms
of this Agreement. All contract, tort, statutory, remedial and/or
any other matters or claims are included within scope of this jury
waiver clause.

h. Notices. Except as otherwise provided in this

Agreement, all notices or other communications hereunder will
be deemed to have been duly given when made in writing and
delivered in person or deposited in the U.S. mail, postage
prepaid, certified mail, return receipt requested, and addressed to
the receiving party as shown above (or any replacement address
notified by the receiving party to the sending party in accordance
with this Section) and marked to the attention of
___________________________________, for Blue Ribbon,
and to the attention of ________________________________
for Contractor.

i. Neither party will disclose the terms of this Agreement

or publish any information concerning the same without the prior
written consent of the other, except that each party may disclose
the terms of this Agreement to its legal, financial and other

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IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their respective duly authorized
representatives.

____________________________________ -- Blue Ribbon Network Member

By:__________________________________________________
Authorized Signatory Date

____________________________________________________
Type or Print Name

Title: ________________________________________________

BLUE RIBBON NETWORK LLC

By:__________________________________________________
Authorized Signatory Date

____________________________________________________
Type or Print Name

Title: ________________________________________________