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City of Lewiston Finance Department Norman Beauparlant, Director of Budget/Purchasing 2014-033 Two Tandem Axle (ten wheelers) 6X4 Truck Chassis & Cab June 11, 2014 Sir/Madam: Sealed bids will be received in the office of the Director of Budget/Purchasing on Tuesday, July 1, 2014 until 2:00 p.m. at which time they will be publicly opened and read aloud on the enclosed specifications for Two Tandem Axle (ten wheelers) 6X4 Truck Chassis & Cab for the City of Lewiston Department of Public Works. The Finance Committee reserves the right to accept or reject any and all proposals. Please use the enclosed envelope or a clearly marked envelope with the bid name and number when submitting your bid. Only sealed bids will be accepted. Faxed bids will not be considered. Sincerely, Norman J. Beauparlant Director of Budget/Purchasing NJB/syt 1 ---PAGE BREAK--- CITY OF LEWISTON, MAINE DEPARTMENT OF PUBLIC WORKS 2 - TANDEM AXLE (Ten Wheeler) TRUCK CAB & CHASSIS (With Plow, Dump Body & Sander) Bid 2014-033 Due: Tuesday, July 1, 2014 by 2:00 p.m. SPECIFICATIONS Specifications for Two TANDEM Axle 6X4 Truck Chassis & Cab (ten wheelers) with Plow, Dump Body and Sander for the Public Works Department. Furnishing and Mounting of this equipment shall be the responsibility of the chassis bidder. The desired equipment will be used by the Public Works Department, Highway Division on and off road, as a dump truck, sander and for snow plowing. The following specification shall be the minimum requirements and the bid shall be of the manufacture’s latest model and design. The bid item must also comply with all applicable Federal and Maine laws. All items appearing in the bidders regular published specifications are assumed to be included in the bidder’s proposal. Bidder’s proposal shall include a complete build data sheet for units purposed The City of Lewiston reserves the right to reject all bids when deemed to be in the best interest of the City, and to waive any minor discrepancy or technicality in the bid specifications. REQUIRMENTS Two Tandem Axle 6x4 truck Chassis & Cab, Freightliner 114SD, IHC7600, Peterbuilt 348, or approved equal. MODEL • Latest YEAR • 2014-2015 WHEELBASE • 195” (approximately, suited to application) C.A. • 126” (min) G.V.W. • 64,000 lbs. (min) ROAD SPEED • 70 MPH CAB • Conventional Air Ride Cab. • Forward tilting hood, w/ access panels to service engine. • Provisions for crank shaft driven PTO (crankshaft adapter, radiator clearance, stationary grille Ect.) • Side hood air intake with inside/outside air and snow door. • Wing type dash. • 2 - Stainless Steel Roof Mounting Brackets for Strobe lights one on each side of cab roof. 2 ---PAGE BREAK--- ENGINE • 12 liter (min) Truck type diesel engine. • 370 H.P. (min) • 1250 ft/lbs. torque (min) • H.D. cooling system, with air operated fan clutch • Dash mounted Cooling Fan override Switch • Multistage Jacobs Brake System • Engine to have 5 year extended warranty • Must have Min. 2010 EPA/CARB Emissions Certification & 2008 CARB Emissions Certification for Clean Idle TRANSMISSION • Allison HD 3000 RDS 6 – Speed. • Push button dash mounted controls. • Transmission to be filled with Trans Synd Fluid. • Transmission to have 5 Year extended warranty DRIVELINE • Meritor 18N Extended Lube Driveline or approved equal FRONT AXLE • Set back I beam type. • 22,000 lb. Capacity (min). • 22,000 lb. Capacity suspension (min) multileaf springs. • Shock absorbers. • Air Operated Right Front Spring Assist for wing plow STEERING • Power steering with dual steering boxes REAR AXLE • Tandem Drive W/ driver controlled traction differentials - both rear axles, defaults to unlock with ignition off. • Driver controlled differential lock both rear axles, defaults to unlock with ignition off • Audible Alarm to sound when differentials are locked. • 46,000 lb. Capacity (min) Hendrickson HMX suspension. • Ratio: geared for 70 MPH BRAKES • Air brakes. • Long stroke brake cans. • Cam type front and rear. • Front brakes 16 ½ “x 6”min. • Rear brakes16 ½ x 7”min. • Spring applied parking brakes on both rear axles. • Forward or high mounted rear axle brake chambers. • 18 cu. Ft. air compressor (min). • Automatic ejection valves, with heater. • Bendix air dryer, with heater and screw on cartridge. • Dust shields. • Aluminum air brake reservoirs. • Completely plumbed for trailer air brakes to rear of truck to include glad hands with caps. • Emergency line on passenger side of truck. • Supply line on driver’s side of the truck 3 ---PAGE BREAK--- FRAME • 120,000 P.S.I. steel (min). • Section modules of 26.70 (min). • R.B.M. of 3,200,000 (min). • Reinforced sections were needed for this application. • Frame length suitable for mounting body and plow gear. • Clear frames rails Inboard and Outboard both rails for 20” from Cab toward back of truck, anything placed in this area must be detailed in your proposal. What the component is and its location from back of cab ELECTRICAL • 12 Volt electrical system. • 160 Amp alternator (min). • Standard battery capacity. • Battery box to have aluminum or plastic cover. • Switch and wiring to control strobe lights mounted on the two stainless steel roof brackets. • 6 Ignition controlled accessory switches with indicator lights wired to a power distribution Box preferably left loose between seats. 30 amp labeled sander controls & 20Amp Labeled, Wing light, Driving light, Camera System, 2-way Radio and Side lights. • Electronic warning system, sounding when Park brake not applied and cab door is opened. • 7 Pin round pin trailer plug wired to rear of truck. • 7 Pin flat RV type connector W/ combined stop/ turn lights and brake controller feed to rear of truck. • Electric brake wiring and controller wired to the 7 pin RV Socket factory installed if available. • Factory installed axillary head light harness and controls for plow lights. • Wired to support ground speed controlled sander controls. • Back up alarm 95 DB min. • Cab marker lights. • Auxiliary Cab side mounted directional lamps. • 12 Volt Power outlet mounted in dash. • Intermittent wipers W/ delay programmed to slowest speed when parking brake is on. • Dual electric horns. • AM-FM dash mounted stereo radio. • Cab Marker lights FUEL SYSTEM • 60 gallon Aluminum Min. • DEF Tank appropriately sized to fuel tank. • Left hand mount WHEELS • Front 22.5”x 9.00” • Rear 22.5”x 8.25” • Powder coated 10 Hole disc Hub Pilot, heavy duty type minimum .472 thickness • Matching Spare Wheel and Tire with Max Traction tread Front and one Rear 4 ---PAGE BREAK--- TIRES • Front: 315/80R22.5 20 Ply Open shoulder Max Traction tread • Rear: 11R22.5 14 Ply Max Traction tread MISCELLANEOUS • Exterior and Interior grab handles both sides of cab. • Deluxe Drives seat, air suspended, high back, w/air lumbar support • Deluxe Passenger seat, air suspended, high back, w/ air lumbar support. • Mirrors, west coast 6x16 heated with 8” stainless steel convex spot mirror. • Stainless Steel Passenger side door, down view mirror. • Engine block heater with plastic receptacle mounted under LH door. • Anti -freeze to – 34 F. • Tinted glass, all around. • Rear window in cab. • Engine tachometer • Hour meter. • Full gauge package. • Dual sun visors. • 3.5” Rubber Front Fender extensions. • Fuel/water separator. • Heavy Duty Front bumper. • Adjustable (tilt-telescope) steering wheel. • Wet type wheel seals (front & rear). • Horizontal muffler w/ vertical stack passenger’s side. • Cup holder’s passenger and driver side. • Three sets of fully functional keys. • Air conditioning (factory). • Air horns. • 2-1/2 pound fire extinguisher and reflective triangles shipped loose PAINT • Yellow EXTENDED WARRANTY • 5 Year Engine and Transmission Warranty Options List options as a separate price per option 1. Engine Diagnostic Software. 2. Communications Cable for electronic diagnostics. 3. Vehicle diagnostic and repair training to include engine transmission and computer laptop diagnostics tool training (8 Hrs. Min. for each of the two shifts) 4. The installation of a Stucchi MP series hydraulic Multi-coupling System between the sander and truck chassis to be built into the hitch plate with a deflector shield on the sides and the top of the device. To include off season cover plates and parking station brackets 5 ---PAGE BREAK--- HYDRAULICS • Rexroth A-10 load sensing hydraulic pump driven from front of Engine with auto shut down and override. • Hydraulic system to be installed to allow easy removal and Installation of sander in dump body. All connections shall be weather proof type and have caps for off season Protection. Exact location to be determined. • Hyd. lines running from controls to sander to be Stainless steel were allowable. • Stainless Steel Hydraulic Tank to be frame mounted at a location to be determined PLOW EQUIPMENT (Viking or American plow gear only) • Front wing post (Viking FH-20 or HP patrol only) • Rear high lift cable tower (Viking H300 or HPF 714 only) • Custom Tilt and Detachable Front Hitch • Dell air control package to control plow & dump functions. • Hydraulic & Air control valves located outside of the cab to be in a weather proof box. • 11’ Full Trip Wing (11’ Edge) W/ spring loaded full trip arms, heavy duty Lower Arm to have shock absorbing spring. (Viking 132WHD RH or American 12DRA only) • 11’ trip edge reversible polymer plow w/ heavy duty Double ram push frame with cushion valve. • Ht of plow 39”-42” (Viking R1142TEP or American 3911 only) • Plow frame painted yellow to match chassis • Fully functioning Head lights & Directional lights • 8” Stainless steel spot mirror mounted to the top of the front wing post exact position to be determined DUMP BODY • 14’ long x 48” sides x 60” tailgate width. • ¼” Hardox 450 Floor and Slanted Tailgate (205,000 psi Min.) • 3/16” Hardox 450 Front and Sides (Min.) • Box top rails • Fully welded construction throughout. • Full depth rear corner posts. • Reinforced front head board • ½ Cab shield, Modified for wing tower clearance, if needed. • Dog house to not extend into body more than 12” • 30 Ton Mailhot Telescopic Hoist, (or approved equal) tied to plow hydraulic system and controls. • Double acting tailgate air operated • Fold down ladder located near the front of body on driver’s side. • Mud flaps front and rear of rear tires W/anti-sail brackets. • Body prop. • LED ICC lighting. • LED Oval strobes High mounted in rear corner posts. • Oval Turn, Brake, Backup and Running lights to be mounted in rear corner posts. • In cab body up Warning Light. • 25 ton Pintle hook with ¾”plate & D-rings • Pioneer EDD 1500 Fully automated deluxe cover system with Asphalt Tarp installed. (or equal) • Painted Yellow to match cab 6 ---PAGE BREAK--- SANDER • 13 ‘L X 62” H 304 Stainless steel Sander body & components 10 Gage stainless steel (min) • Sander to have lifting points at all four corners. • 12” stainless steel spill shields front and rear. • Oval LED Directional & Running lights to be high mounted on sander body in stainless steel boxes, • Truck Star LED 1492115) Utility for backup lights wired into back up circuit exact location to be determined • Truck Star LED 1492115) for the Spinner light (wired into the running light system) exact location to be determined. • Lights to be wired w/7 pole RV plug to plug into trailer socket. • Truck Light # 50400 junction box(s) and corresponding fittings to be used for all aftermarket electrical installations • Sander to be mounted in such a way it can be quickly and easily removed and installed. • All electrical and hydraulics to be quick connecting with caps for off season storage. • Heavy duty 3/8’ thick conveyor chain flights every other link. • Heavy duty top screen. • Sander attached by the Rear dump body latches and front tie downs to the dump body allowing the sander to be quickly removed without tools. • Extended grease lines to the rear of sander for ease of service. • 2” drive shaft and 1 ¼” Idler shaft. • Sander conveyor system to have center Idler sprocket as well. • Spring loaded front Idler assembly • Heavy Duty slide out Storage Leg Stand Kit Installed. • Heavy Duty Guide Wheels mounted on the front of sander. • Enclosed tip up delivery system. • Two Calcium tanks with electric liquid pump Approx. 135 Gal capacities each SANDER CONTROLS • Control system to have Ground speed sander controls for Liquid and granular. • System is to be upgradable to include Drive–By downloading. • Control system to be either Compu-spread model 550 or Cirus Spread smart Model RX • (NO Substitutions) • Operator and mechanics training BODY COMPANY MISCELLANEOUS • Truck Star Part # 8881100 back up camera system installed. • 2-Truck Star Amber LED Flood lights (#1492116) mounted on wing tower to light up the area in front of and around wing when it is down. Exact position to be determined. • All add on electrical components to get power from supplied dash controlled junction box in cab. The junction box is to pick up power only; anything that needs to have an enclosure will have to be supplied by that vender. • All Wiring and Cables to have wire loom (or equal) covering over it. 7 ---PAGE BREAK--- MANUALS • 2 Sets of Operator, Service, Repair, Maintenance and Parts Manuals for Truck and all major accessories SERVICE The Public Works department must be satisfied that the Chassis and Equipment dealers maintain adequate service and parts facilities, with shop and field services performed by factory trained mechanics. Within 75 mile radius of the 103 Adams Avenue Facility. TRAINING To be held at LPW yard 103 Adams Ave. at time of delivery By factory trained representatives 8 ---PAGE BREAK--- CITY OF LEWISTON, MAINE DEPARTMENT OF PUBLIC WORKS 2 - TANDEM AXLE (Ten Wheelers) TRUCK CAB & CHASSIS (With Plow, Dump Body & Sander) Bid 2014-033 Due: Tuesday, July 1, 2014 by 2:00 p.m. PROPOSAL/QUESTIONNAIRE FORM NOTE: Bids will not receive consideration unless the bidder answers all questions on this form and return the attached proposal/questionnaire form. Truck Chassis & Cab Unit 1 $ Year: Make: Model: Plow Equipment $ Make: Model: Dump Body $ Make: Model: Sander $ Make: Model: TOTAL: Truck Chassis w/plow equipment, dump body & sander $ Options: 1. Engine Diagnostic Software $ 2. Communications cable for electronic diagnostics $ 3. Vehicle diagnostic & repair training to include engine transmission & computer laptop diagnostics tool training (8 hrs. min. for each of the two shifts) $ 4. Installation of a Stucchi MP series hydraulic Multi-coupling system between sander & truck chassis to be built into the hitch plate with a deflector shield on the sides & top of the device. To include off season cover plates & parking station brackets. $ Truck Chassis & Cab Unit 2 $ Year: Make: Model: Plow Equipment $ Make: Model: Dump Body $ Make: Model: Sander $ Make: Model: TOTAL: Truck Chassis w/plow equipment, dump body & sander $ Options: 1. Engine Diagnostic Software $ 2. Communications cable for electronic diagnostics $ 3. Vehicle diagnostic & repair training to include engine transmission & computer laptop diagnostics tool training (8 hrs. min. for each of the two shifts) $ 4. Installation of a Stucchi MP series hydraulic Multi-coupling system between sander & truck chassis to be built into the hitch plate with a deflector shield on the sides & top of the device. To include off season cover plates & parking station brackets. $ Total Unit 1 & 2 w/plow, dump body & sander complete $ 9 ---PAGE BREAK--- QUESTIONNAIRE YES NO Model Latest Year 2014-2015 Wheel Base 195” (approx., suited to application) C.A. 126” (min.) G.V.W. 64,000 lbs. (min.) Road Speed 70 mph Cab Conventional Air Ride Cab Forward tilting hood, w/access panels to service engine Provisions for crank shaft driven PTO (crankshaft adaptor, radiator clearances, stationary grill etc.) Side hood air intake w/inside/outside air & snow door Wing type dash 2 stainless steel roof mounting brackets for strobe lights, one on each side of cab roof Engine 12 liter (min) truck type diesel engine 370 HP (min) 1,250 ft/lbs torque (min) H.D. cooling system, w/air operated fan clutch Dash mounted cooling fan override switch Multistage Jacobs Brake System Engine to have 5 year extended warranty Min. 2010 EPA/CARB Emissions Certification & 2008 CARB Emissions Certification for Clean idle Transmission Allison HD 3000 RDS 6 speed Push button dash mounted controls Transmission filled w/Trans Synd Fluid Transmission have 5 year extended warranty Driveline Meritor 18N Extended Lube Driveline or approved equal Front Axle Set back I beam type 22,000 lb. capacity (min) 22,000 lb. capacity suspension (min) multileaf springs Shock absorbers Air operated right front spring assist for wing plow Steering Power steering w/dual steering boxes Rear Axle Tandem drive w/driver controlled traction differentials – both rear axles, defaults to unlock w/ignition off Driver controlled differential lock both rear axles, defaults to unlock w/ignition off Audible alarm to sound when differential are locked 46,000 lb. capacity (min) Hendrickson HMX suspension Ratio: geared for 70 mph 10 ---PAGE BREAK--- QUESTIONNAIRE YES NO Brakes Air brakes Long stroke brake cans Cam type front & rear Front brakes 16½” X 6” (min) Rear brakes 16½” X 7” (min) Spring applied parking brakes on both rear axles Forward or high mounted rear axle brake chambers 18 Cu Ft air compressor (min) Automatic ejection valves, w/heater Bendix air dryer, w/heater & screw on cartridge Dust shields Aluminum air brake reservoirs Completely plumbed for trailer air brakes to rear of truck to include glad hands w/caps Emergency line on passenger side of truck Supply line on driver’s side of truck Frame 120,000 PSI steel (min) Section modules of 26.70 (min) R.B.M. of 3,200,000 (min) Reinforced sections where needed for this application Frame length suitable for mounting body & plow gear Clear frames rails inboard & outboard both rails for 20” from cab toward back of truck Electrical 12 V electrical system 160 Amp alternator (min) Standard battery capacity Battery box have aluminum or plastic cover Switch & wiring control strobe lights mounted on the 2 stainless steel roof brackets 6 Ignition controlled accessory switches w/above ref. items Electronic warning system, sounding when parking brake not applied & cab door is open 7 Pin round pin trailer plug wired to rear of truck 7 Pin flat RV type connector w/combined stop/turn lights & brake controller feed to rear of truck Electric brake wiring & controller wired to the 7 Pin RV Socket – factory installed Factory installed auxiliary headlight harness & controls for plow lights Wired to support ground speed controlled sander controls Back up alarm 95 DB (min) Cab marker lights Auxiliary cab side mounted directional lamps 12 V power outlet mounted in dash Intermittent wipers w/delay programmed to slowest speed when parking brake is on Dual electric horns AM-FM dash mounted stereo radio Cab marker lights 11 ---PAGE BREAK--- QUESTIONNAIRE YES NO Fuel System 60 gallon aluminum (min) DEF Tank appropriately sized to fuel tank Left hand mount Wheels Front: 22.5” X 9.00” Rear: 22.5” X 8.25” Powder coated 10 hole disc hub pilot, HD type (min) .472 thickness Matching spare wheel & tire w/Max Traction tread Front & Rear Tires Front: 315/80R22.5 20 ply open shoulder Max Traction tread Rear: 11R22.5 14 ply Max Traction tread Miscellaneous Exterior & interior grab handles both sides of cab Deluxe drives seat, air suspended, high back, w/air lumbar support Deluxe passenger seat, air suspended, high back, w/air lumbar support Mirrors, west coast 6X16 heated w/8” stainless steel convex spot mirror Stainless steel passenger side door, down view mirror Engine block heater w/plastic receptacle mounted under LH door Anti-freeze to -34°F Tinted glass, all around Rear window in cab Engine tachometer Hour meter Full gauge package Dual sun visors 3.5” rubber front fender extensions Fuel/water separator HD front bumper Adjustable (tilt-telescope) steering wheel Wet type wheel seals (front & rear) Horizontal muffler w/vertical stack passenger’s side Cup holders passenger & driver side Three sets of fully functional keys Air Conditioning (factory) Air horns 1½ lb fire extinguisher & reflective triangles shipped loose Paint Yellow Extended Warranty 5 Year Engine & Transmission 12 ---PAGE BREAK--- QUESTIONNAIRE YES NO Hydraulics Rexroth A-10 load sensing hydraulic pump driven from front of engine w/auto shut down & override Hydraulic system installed to allow easy removal & installation of sander in dump body. All connection weatherproof type & have caps for off season protection Hydraulic lines run from controls to sander in stainless steel where allowable Stainless steel hydraulic tank frame mounted Plow Equipment (Viking or American plow gear only) Front wing post (Viking FH-20 or HP patrol) Rear high lift cable tower (Viking H300 or HPF 714) Custom tilt & detachable front hitch Dell air control pkg to control plow & dump functions Hydraulic & air control valves located outside the cab in weatherproof box 11’ Full Trip Wing (11’ edge) w/spring loaded full trip arms, HD lower arm have shock absorbing spring (Viking 132WHD RH or American 12DRA) 11’ trip edge reversible polymer plow w/HD double ram push frame w/cushion valve Ht of plow 39”-42” (Viking R1142TEP or American 3911) Plow frame painted yellow to match chassis Fully functioning head lights & directional lights 8” stainless steel spot mirror mounted to top of front wing post Dump Body 14’ long X 48” sides X 60” tailgate width ¼” Hardox 450 floor & slanted tailgate (205,000 psi min) 3/16” Hardox 450 front & sides (min) Box top rails Fully welded construction throughout Full depth rear corner posts Reinforced front head board ½ Cab shield, modified for wing tower clearance, if needed Dog house not extend into body more than 12” 30 ton Mailhot Telescopic Hoist (or approved equal) tied to plow hydraulic system & controls Double acting tailgate air operated Fold down ladder located near front of body on driver’s side Mud flaps front & rear of rear tires w/anti-sail brackets Body prop LED ICC lighting LED oval strobes high mounted in rear corner posts Oval turn, brake, backup & running lights mounted to rear corner posts In cab body up warning light 25 ton Pintle hook w/3/4” plate & D-rings Pioneer EDD 1500 fully automated deluxe cover system w/asphalt tarp installed (or equal) Painted yellow to match cab 13 ---PAGE BREAK--- QUESTIONNAIRE YES NO Sander 13’ L X 62” H 304 stainless steel sander body & components 10 gauge stainless steel (min) Lifting points @ all four corners 12” stainless steel spill shields front & rear Oval LED directional & running lights high mounted on sander body in stainless steel boxes Truck Star LED (#1492115) utility for backup lights wired into back up circuit Truck Star LED (#1492115) for spinner light (wired into running light system) Lights wired w/7 pole RV plug into trailer socket Truck light #50400 junction box(s) & corresponding fittings used for all aftermarket electrical installations Sander mounted in such a way it can be quickly & easily removed/installed All electrical & hydraulics quick connecting w/caps for off season storage Heavy Duty 3/8” thick conveyor chain flights every other link Heavy Duty top screen Sander attached by rear dump body latches & front tie downs to the dump body to allow sander to be quickly removed w/o tools Extended grease lines to rear of sander for ease of srvc 2” drive shaft & 1¼” Idler shaft Sander conveyor system has center Idler sprockets too Spring loaded front Idler assembly Heavy Duty slide out storage leg stand kit installed Heavy Duty guide wheels mounted on front of sander Enclosed tip up delivery system Calcium tanks w/electric liquid pump (approx.. 135 gallon capacity each) Sander Controls Control system has ground speed sander controls for liquid & granular System upgradable to include Drive-By downloading Control system is either Compu-spread model 550 or Cirus Spread Smart model RX Operator & mechanic training Body company miscellaneous Truck Star Part #8881100 back up camera system installed Truck Star amber LED flood lights (#1492116) mounted on wing tower All add on electrical components get power from supplied dash controlled junction box in cab Junction box picks up power only All wiring & cables have wire loom (or equal) covering over it Manuals sets of Operator, Service, Repair, Maintenance & Parts Manuals for truck & all major accessories 14 ---PAGE BREAK--- QUESTIONNAIRE YES NO Service Chassis & equipment dealers maintain adequate service & parts facilities, w/shop & field services performed by factory trained mechanics. Within 75 mile radius of 103 Adams Avenue facility Training Training being done by factory trained representative at delivery time & held @ LPW yard @ 103 Adams Ave State Delivery from date of order Days State Terms for Payment To receive consideration, the bidder must enclose all of the literature necessary to properly evaluate this bid. Service: The City of Lewiston must be satisfied that the equipment dealer maintains adequate service facilities within reasonable distance of Lewiston and parts on hand with shop and field services performed by factory trained technicians. General: The unit shall be completely serviced, all adjustments made and be ready to work when delivered. Training: Within one week of delivery, a qualified representative will be made available for approximately four hours of operator training and approximately four hours of maintenance personnel training. Payment: Payment will be made within 30 days after delivery and training of the truck/catch basin cleaner F.O.B. 103 Adams Avenue, Lewiston, Maine 04240. If the bidder takes any exception to these specifications, he/she is to list them in detail on this sheet and not in separate correspondence, otherwise strict compliance will be mandatory: COMPANY SIGNED BY PRINTED (name & title) ADDRESS TELEPHONE FAX # E-MAIL DATE 15