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OSHA Strategic Partnerships Program > Region 5 > #526 Partnership Agreement
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Underground Contractors Association of Illinois  Occupational Safety and Health Administration
OSHA STRATEGIC PARTNERSHIP PROGRAM (OSPP)

A PARTNERING PROGRAM OF THE
UNDERGROUND CONTRACTORS ASSOCIATION
OF ILLINOIS (UCA-IL)
AND
THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA)
As Amended on November 21, 2006
Expiration Date is November 21, 2009

Renewal of OSHA Strategic Partnership Program (OSPP) with the Underground Contractors Association of Illinois (UCA-IL)

I. Identification of Partners

The United States Department of Labor Occupational Safety Health Administration (OSHA), Region V, Illinois Area Offices and the Underground Contractors Association of Illinois (UCA-IL) mutually recognize the importance of providing a safe and healthful work environment for employees engaged in the underground construction industry. In working together as partners, we are committed to achieving a reduction of injuries, illnesses and fatalities in the underground construction industry through means of open communication, promoting recognition for construction safety excellence, and sharing knowledge of the best industry technology, innovations and work practices that improve safety and health performance. As for the background of the Underground Contractors Association of Illinois (UCA-IL), it consists of contractor members that are underground utility contractors, who specialize in utility, cable, electric, gas, fiber optic, telephone, water, storm water, and sewer installations, maintenance and repair. Other work specialties include tunneling, auger boring, directional drilling, road repairs and other underground specialty work related to underground infrastructure projects. The Underground Contractors Association of Illinois (UCA-IL’s) associate members are engaged in the manufacture, production and distribution of construction materials, labor and services utilized by underground utility contractor members.

II. Purpose and Scope

This partnership represents a voluntary agreement which affords the Underground Contractors Association of Illinois members with an alternative to traditional OSHA enforcement. The purpose of this partnership is to foster open communication between OSHA, The UCA-IL and its Members. In doing so, there will be cooperation in developing training, promotion of worker safety and health and the prevention of discrimination for those with safety concerns.

III. Goals and Strategies

OSHA and UCA-IL are committed to continuing to working together through the OSHA Strategic Partnership Program ("OSPP") as partners to achieve construction workplace safety through the following shared goals and strategies:

 
GOALS STRATEGIES MEASUREMENT
  1. Reduce the aggregate incidence rate of Participating Companies for workplace injuries and Illnesses involving lost or restricted workdays
  1. Using the Bureau of Labor Statistics (BLS) data, develop a protocol or check list that will cover the most common injuries and illnesses that happen at underground worksites.
     
  2.  Conduct and document monthly self audits.
     
  3.  UCA-IL administrator shall perform 1 of the monthly jobsite safety audits per participating company per year.
  1. Baseline1 injury and illness data of lost and restricted work days.
     
  2. Compile annual injury and illness data of lost and restricted work days to determine the incidence rate of Participating Companies.
     
  3. Perform an annual comparison of the baseline to the annual incidence rate.
     
  4. Participating Company’s monthly jobsites audits will be compared to the audit performed by the UCA-IL administrator.
  1. Annually increase the membership in the OSPP
  1. Advertise partnership in UCA-IL Pipeline Newsletter
     
  2. Bi-annually safety talk meeting.
     
  3. Encourage members to share their partnership experience with other contractors.
     
  4. OSHA update article in UCA-IL newsletter.
  1. Annually compare partnership membership numbers.
  1. Increase the training conducted by participating companies.
  1. Require UCA-IL’s OSHA-authorized 10-Hour training course especially designed for the Underground Construction Training Industry, for all supervisory and core field personnel (foreman).
     
  2. Develop ideas for tool box talks and articles for the "Safety Angle" section of UCA-IL newsletter, which are related to recorded injury incidents.
  1. Annual comparison of training sessions held.
     
  2. Annual number of employees, supervisors, superintendents and foremen in the training sessions.
  1. Reduce Participating Companies’ violations of OSHA regulation 1926 – Subpart P – Excavation.
  1. Training regarding past OSHA violations
     
  2. Promote the use of the Illinois On-Site Consultation Service
     
  3. OSHA’s open door policy to UCA-IL Safety Administrator for answering questions and helping in unusual or difficult circumstances.
  1. Baseline violation data from OSHA
     
  2. Annual violation data
     
  3. Comparison of baseline to the annual

IV. Criteria for Participation:
  1. As a prerequisite for acceptance into the OSPP by OSHA, a Participating Company must submit an executed (1) Participating Company’s Application Form (Exhibit ‘A’) and (2) a Participating Company’s Agreement with the UCA-IL (Exhibit ‘B’) to UCA-IL's Administrator.

  2. The Participating Company’s Application Form to UCA-IL's Administrator requires a certification that a comprehensive written safety and health program is currently in effect for the Participating Company's employees and is substantially similar to either:

    • The UCA-IL Safety and Risk Management Program, or
    • OSHA’s "Safety and Health Program Management Guidelines" of January 26, 1989 in FRN 54:3904-3916, or
    • American National Standards Institute’s (ANSI) A-10.38, "Basic Elements of an Employer Program to Provide a Safe and Healthful Work Environment," or
    • Another safety and health program (a copy of which must be attached to the OSPP Application Form) which meets the minimum safety standards set forth in any one of the three programs, identified above.
  3. A Participating Company shall certify to UCA-IL's Administrator that it enforces its safety policies and procedures by holding supervisor(s) and employee(s) accountable for the Participating Company's safety rules and OSHA's regulations.

  4. A Participating Company shall conduct and document monthly self-audits and submit the audits quarterly to UCA-IL’s Safety Administrator via electronic mail (email).

  5. A Participating Company shall within one year of obtaining approval of its application into OSPP provide to UCA-IL's Safety Administrator verification that all supervisory/core field personnel who are engaged in construction activities have completed the OSHA 10-Hour Training Course for the Underground Construction Industry.

  6. A Participating Company shall further agree to provide such additional employee training as the Participating Company deems necessary to achieve the goals of the OSPP. A Participating Company should note that the training referenced above does not excuse an employer's obligation to comply with specific OSHA training standards.

  7. A Participating Company shall annually provide its OSHA Forms 300 and 300A to the UCA-IL's Safety Administrator. UCA-IL's Administrator will conduct a summary analysis of pertinent safety related information and shall share that information with OSHA as part of UCA-IL’s obligation to monitor the achievement of the goals and measurements of the OSPP. The purpose of the summary analysis is to assist UCA-IL's Safety Administrator and OSHA in preparing an annual report necessary for an evaluation of the success of OSPP. UCA-IL’s Safety Administrator will provide an aggregate (summary format) of the information to OSHA, which does not identify individual participating firms.
V. Benefits

Contractors participating in this partnership agreement will remain subject to OSHA inspections and investigations in accordance with established agency policies and procedures, and the terms provided for in this OSPP Agreement. OSHA will continue to investigate fatalities and catastrophes involving participating members, and to investigate all formal2 complaints and referrals received by the Illinois Area Offices. OSHA will use telephone and fax to question Participating Companies about non-formal3 complaints, except those non-formal complaints involving potential cave-in hazards where inspections will be conducted. The Participating Company will advise OSHA of the corrective measures taken to abate any safety deficiencies associated with a non-formal complaint.

Additionally, the benefits provided for in this OSPP apply only to those Participating Companies "working in Illinois" who have had no willful and repeated serious violations in the last three years, and no fatalities or catastrophes within the last three years that resulted in serious, repeat, or willful citations related to the incident.

OSHA shall provide the following services and benefits to UCA-IL and its Participating Companies in the OSPP:
  1. OSHA, through its Area Directors, will provide a representative to meet quarterly with the UCA-IL Safety Administrator and Participating Companies in order to discuss current jobsite findings, current violation trends, and possible corrective measures.

  2. OSHA will not issue citations to Participating Companies for an other-than-serious4 hazard, which is
    (1) abated immediately in the presence of the OSHA compliance officer (CSHO), or
    (2) abated prior to an employee’s exposure to the hazard, provided that the Participating Company advises the CSHO of the time and date which the hazard was corrected (abated).

  3. Annually OSHA will conduct random on-site verification inspections/evaluations5 of up to no more than a total of 10% of Participating Companies, to ensure that the Participating Companies are fulfilling their commitment to the OSPP.
    The verification inspection/evaluation must be conducted on at least one Participating Company. The Illinois offices will share the results of onsite verification inspections among themselves and the UCA-IL’s Safety Administrator.

  4. If a Participating Company is the sole or primary contractor at a site (and has not had a partnership verification inspection) and is subjected to a programmed inspection6 by OSHA, that inspection would be a focused inspection7 and the inspection would be counted as one of the 10% minimum required annual verification inspections of Participating Companies. On focused inspections found to be in-compliance, OSHA will send an in-compliance letter to the company and an email copy to the UCA-IL. Upon completion of a successful focused or verification inspection, the Participating Company may be exempt from the Programmed inspection list for one year. Sites that have serious hazards in plain view will continue to be inspected. As with all focused inspections, if significant hazards are observed, the scope of the inspection may be expanded.

  5. During an OSHA inspection of a multi-employer work-site, a Participating Company that is present and has had a successful verification inspection during the calendar year at another work site will be exempted from the inspection unless the compliance officer can document that the Participating Company is responsible for employee exposures to observed serious hazards such as (1) falls, (2) confined-space entry hazards, (3) electrocution hazards, (4) trenching hazards, (5) struck-by and caught-in/between, or (6) any other serious hazard.

  6. If an inspection is the result of a formal complaint, the Participating Company is entitled to a copy of this formal complaint, and the inspection will only address the complaint item(s), related safety and health programs, injury and illness records, and or other hazards in plain view of the CSHO. When the requested programs or records are located offsite, the company will have 4 hours to retrieve the documents.

  7. If cited by OSHA, UCA-IL’s Participating firms may receive the maximum allowable good-faith discount of 35%, in addition to any other penalty reduction factors that may be available.

  8. At the request of a Participating Company, an OSHA Area Director of the jurisdiction or their representative will meet with UCA-IL's Administrator and the Participating Company to address the Participating Company’s concerns
VI. Annual Evaluation:

Annually each participant will submit to the UCA-IL’s Administrator the following information:
  1. OSHA form 300A and total man hours worked for the company and those worksites lasting for longer than one year;

  2. Changes in the company’s Safety and Health programs;

  3. Safety and health training records to include a list of topics covered in safety talks and number of employees in attendance.

  4. The report will be consistent with the latest annual partnership evaluation format provided in Appendix C of the OSPP Directive, CSP 03-02-002.
VII. OSHA Verification (Monitoring)

The UCA-IL Administrator shall annually provide to OSHA an annual report summarizing the OSHA Incidence Rates of the Participating Companies.

UCA-IL and OSHA will evaluate the effectiveness of this Partnership Agreement annually following the UCA-IL Administrator’s submission of its annual report. The OSPP's effectiveness shall be measured through the achievement of the goals stated in this Partnership Agreement, utilizing the information contained in the annual report, which summarizes the Participating Companies’ OSHA Forms 300 and 300A.

VIII. OSPP Management and Operation

This partnership shall be administered by the UCA-IL. Each partner shall designate a representative to sit on the OSHA Partnership Committee. This OSHA Partnership Committee shall be responsible for administration of the partnership, application review, and approval, as well as any resolution of any issues which may arise with the partnership in effect. The Chicago North OSHA area office shall represent OSHA as an advisor to the OSHA Partnership Committee. The UCA-IL’s Administrator and/or Executive Director shall represent the UCA-IL as its advisor to the OSHA Partnership Committee

The OSHA Partnership Committee will hold quarterly conference calls/meetings to track, analyze and share information on partnership activities and results. At least annually, the OSHA Partnership Committee will meet to evaluate the effectiveness of the Agreement. These meetings will include agenda items, such as:
  • Evaluating data and partnership impact.
  • Identifying UCA-IL members with outstanding safety and health excellence.
  • Share information on best practices that improve safety and health performance.
The Occupational Safety and Health Administration agrees to:
  • Work with the UCA-IL and/or its members to provide free safety and health information, training, and training materials.
  • Provide training materials, through the UCA-IL, to help employers understand and comply with OSHA regulations and to implement effective safety and health management systems.
  • Ensure that Compliance Safety and Health Officers (CSHOs) are knowledgeable of partnership requirements and encourage them to provide assistance as requested by the UCA-IL and/or its members.
  • Not issue citations for other than serious violations, provided the abatement of violations is observed by the compliance officer.
  • Track, analyze, and share information on activities such as:
    • Current relevant OSHA inspection findings.
    • Relevant regulatory interpretations.
    • Current industry statistics.
UCA-IL agrees to:
  • Host safety committee meetings, quarterly and annually.
  • Administer the program by providing staff support and facility usage.
  • Promote programs through its Pipeline Newsletter, and other UCA-IL sanctioned activities.
  • Act as first point of contact for perspective participating firms.
  • Recruit and retain program participants.
  • Provide resources to support program participants and prospective participants.
  • Annually perform one monthly job-site audit of each participating company.
IX. Employee and Employer Rights

This partnership does not preclude employees and/or employers from exercising any right provided under the OSH Act, nor does it abrogate any responsibility to comply with rules and regulations adopted pursuant to the Act.

X. Terms of OSPP

This agreement will expire on the 8th day of October 2009. Should either party choose to withdraw prior to that date, 30 days written notice will be given, either party may also propose modification or amendment of the agreement.

Participation will be terminated if one or more of the following occurs:
  1. A site inspection reveals eligibility requirements are not being met.
  2. A participating company has falsified information on the application or supporting records
  3. A participating company takes other such actions that may be determined to be grounds for termination by the Area Director.

Signed this 21 day of November 2006:
 


 
Diane Turek
Area Director
Chicago North Area Office


 
Terry Barnett
President
Underground Contractors Association of Illinois


 
Gary Anderson
Area Director
Calumet City Area Office
 


 
Kathy O’Connell
Area Director
North Aurora Area Office
 


 
Nick Walters
Area Director
Peoria Area Office
 

 
1Baseline is defined as starting point used for critical observation in comparison to future injury and illness data. For example, 2006 data (baseline) will be compared to 2007.
2Formal Complaint. Complaint made by a current employee or a representative of employees that is signed by at least one current employee or employee representative.
3Non-formal Complaint. Any complaint alleging safety or health violations that does not meet the requirements of a formal complaint.
4An Other-Than-Serious hazard (violation) is defined as an existing hazard for which…
  1. There is no present exposure to an employee due to its remoteness to the location of work presently being performed by any employees of the participating firm, and which the Participating Company agrees to abate in the presence of the compliance officer (CSHO); or…
  2. A type of hazardous condition, where the most serious injury or illness likely to result from the hazardous condition cannot be reasonably predicted to cause death or serious physical harm to an exposed employee, but could have a direct and immediate relationship to their safety and health.
5A Verification Inspection/Evaluation is defined as a job-site visit by OSHA of an OSPP Participating Company to ensure that the company is complying with the OSPP’s criteria.
6A Programmed Inspection is defined as an inspection which is scheduled according to a national scheduling plan, which uses objective and neutral criteria. The company would be randomly chosen for inspection because of an OSHA special emphasis program.

Unprogrammed Inspections could be scheduled in response to:
  1.  Non-formal complaints, oral or unsigned complaints by former employees or non-employees, regarding job-site hazards.
  2. Formal complaints or referrals, oral or signed complaints by an employee or a representative of an employee (such as the employee’s union), regarding job-site hazards.
7A Focused Inspection is one which is limited to the 4 high hazard emphasis areas (falls, caught in/between (trenching hazards), electrocution and struck-by) or any other serious hazard observed during the inspection.

 
Underground Contractors Association of Illinois
EXHIBIT ‘A’ TO OSPP AGREEMENT
 
PARTICIPATING COMPANY’S APPLICATION FORM FOR
ACCEPTANCE INTO THE OSHA STRATEGIC PARTNERSHIP PROGRAM (OSPP)

Date of Application: _____________________

Company Name of Applicant/Participating Company:_______________________________________________________________

Address and Phone Number of your Main Office:__________________________________________________________________
_______________________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:
  1. Identify the type of construction work which best describes the type of work performed by your firm using the business classifications shown below:

    The following Business Classification identifies the type of work performed by the Participating Company:
Standard Industrial Classification (SIC) Codes/Division "C" Construction

SIC Major Group 16 – Heavy Construction, i.e. Construction other than Building Construction Contractors.
  • Industry Group 161: Highway and Street Construction
    SIC #161 – Highway & Street Construction, Except Elevated Highways (NAICS – 237310)

  • Industry Group 162: Heavy Construction, Except Highway & Street
    SIC #1622 (NAICS - 237310) – Bridges, Tunnel & Elevated Highway Construction
    SIC #1623 – (NAICS – 237210) Water, Sewer, Pipeline, Communications & Power Line
    SIC #1629 (NAICS – 237990) – Heavy Construction, not classified elsewhere
This firm performs the following work based upon the SIC Codes above:
 
SIC#
_______
_______
_______
_______
_______
_______
  1. Indicate which of the following Craft Trades are employed by your Firm (Circle all that apply):
    1) Operating Engineers 2) Laborers 3) Carpenters 4) Teamsters 5) Others

  2. Approximate the yearly average number of job-site employees:

  3. Attach a copy of the Applicant's OSHA Forms 300 and 300A for the most recent year available.

  4. Provide the name and phone number of your Safety Director or Person responsible for your firm's Safety Program:__________________________________________________________

    _________________________________________________________________

  5. Do you currently have a written safety program: Yes ________ No ________

    If you answered Yes, then identify the program from one of the following programs (check one of the four boxes below):
     
    UCA-IL Safety and Risk Management Program; or
     
    OSHA's "Safety and Health Program Management Guidelines" of January 26, 1984 and FRN 54:3904-3916; or
     
    American National Standards Institute "ANSI" a-10.38, "Basic Elements of An Employer Program to Provide a Safe and Healthful Work Environment"; or
     
    The Participating Companies program is not one of the three programs identified above. The name of the program and its author are identified below and a copy of the program is attached to this application: ____________________________________________
    ______________________________________________________
    ______________________________________________________

I hereby certify that all information submitted on this application is true and accurate.

Application Completed By: ___________________________________________

Title:_________________________________Date:________________________

Please Return the Application Form to UCA-IL’s Safety Administrator:

Safety Alliance, LTD.
ATTN: Dave Soderman
145 W. Main Street
Barrington, IL 60010
Telephone: (847) 842-0453


 
EXHIBIT ‘B’ TO OSPP AGREEMENT
Underground Contractors Association of Illinois

PARTICIPATING COMPANY’S AGREEMENT WITH THE UCA-IL OF ILLINOIS

This OSPP Participating Company Agreement (hereinafter "Participant Agreement"), is hereby entered into by and between the Underground Contractors Association of Illinois ("UCA-IL"), with offices located at 500 Park Boulevard, Suite 154C, Itasca, Illinois 60143, acting as a third party administrator to OSHA, and the Participating Company:

____________________________________________________________________with its main offices located at

_______________________________________________________________(hereinafter "Participating Company").

WHEREAS, Participating Company wishes to participate in the OSHA Strategic Partnership Program (OSPP), a copy of which has been provided to the Participating Company and is incorporated herein by reference; and

WHEREAS, UCA-IL will be providing certain third party administrative services for OSHA and the Participating Company as required by OSPP for the benefit of the Participating Company and OSHA.

NOW, THEREFORE, for and in consideration of the third party administrative services and other good and valuable consideration, UCA-IL and Participating Company agree as follows:

I. TERM

The term of this Participant Agreement shall be from the date of Participating Company's acceptance into The OSPP by OSHA until such time as UCA-IL, OSHA or the Participating Company terminates this Partnership Agreement.

II. SERVICES TO BE PROVIDED:

UCA-IL will provide to the Participating Company the third party administrative services described in The OSPP.

III. SERVICE FEES AND EXPENSES

Upon execution of this Participant Agreement, Participant will not be charged any fees for its third party administrative services as described in the OSPP.

IV. STATUS OF UCA-IL’S THIRD PARTY ADMINISTRATOR

UCA-IL will act as a third party administrator of the OSPP and will process both 1) the OSPP Application Form to UCA-IL and 2) the OSPP Participating Form Agreement with UCA-IL for OSHA in order to facilitate the evaluation by OSHA of the achievement of the goals set forth in this Partnership Agreement. UCA-IL's third party administrator status with respect to its participation in OSPP shall not be considered by OSHA or a Participating Company as a determination that the Participating Company's safety program does or does not meet any applicable legal, health or safety standard, such as 1) any federal safety or health statute or regulation; or 2) any state or local statutes or regulations that also address occupational safety or health. In addition, UCA-IL's third party administration of OSPP is not an attempt by UCA-IL to determine whether the Participating Company is exercising a "reasonable standard of care" or whether its safety program insures a "safe and healthful working environment" for either the Participating Company, OSHA, or any of the Participating Company's employees. UCA-IL expressly disclaims any liability or other responsibility for any claim that may arise out of the Participating Company's performance of its obligations under OSPP, any federal or any state safety or health ordinance or regulation. OSHA and the Participating Company accepted into OSPP expressly acknowledge and agree to this limited role of UCA-IL in The OSPP and UCA-IL's complete disclaimer of liability as a third party administrator of OSPP.

V. PARTICIPATING COMPANY'S COMMITMENT AND ROLE

The Participating Company expressly acknowledges that it has read Section IV of the OSPP agreement between UCA-IL and OSHA and that the Participating Company certifies the representations contained therein are true. The Participating Company's Commitment and Role set forth in Section IV of the OSPP agreement are incorporated herein as though set fully forth and repeated at length.

VI. CONFIDENTIALITY

UCA-IL and UCA-IL's Safety Administrator shall not disclose to any third party (other than OSHA) the information received from the Participating Company by UCA-IL as the third party administrator, except with Participating Company's written permission or as is reasonably necessary to:
  1. Carry out UCA-IL's obligation under the OSPP Partnering Agreement,
  2. Delegate UCA-IL's obligations to its Safety Director, or
  3. Meet UCA-IL's legal obligations, and/or as directed by a court of law with proper jurisdiction.
VII. INDEMNIFICATION AND INSURANCE

Participating Company hereby agrees to indemnify and hold harmless UCA-IL, its officers, employees, safety administrator, volunteers, representatives, agents, attorneys and consultants from any and all claims, suits or actions, whether in law or equity, or other, made or brought against UCA-IL or the Participating Company including, but not limited to, any and all costs, attorneys' fees, and expenses, which result from any such claim, suit or action arising out of the OSPP or this Participant Agreement, or which result from any intended or negligent statements, misstatements, actions or inaction on the part of UCA-IL and its Safety Administrator or the Participating Company, including, but not limited to, non-compliance with any findings, recommendations and/or requirements of OSHA, UCA-IL or UCA-IL's Safety Administrator under this Participant Agreement or the OSPP.

VIII. CANCELLATION

This Agreement may be canceled by UCA-IL, OSHA or the Participating Company after acceptance of the Participating Company into OSPP, with or without cause and for any reason, at any time by written notice of the termination to UCA-IL, OSHA or Participating Company.

VIII. MISCELLANEOUS
  1. All notices, or time periods applicable thereto, required or permitted under this Participant Agreement shall be effective as to UCA-IL upon the mailing thereof in a stamped or postage-paid envelope to UCA-IL’s Administrator at the following address:

    Safety Alliance, LTD.
    ATTN: Dave Soderman
    145 W. Main Street
    Barrington, IL 60010
    Telephone: (847) 842-0453

    and as to Participating Company, at the following address:
    _____________________________
    _____________________________
    _____________________________
    Attention:_____________________

  2. The provisions of this Participant Agreement are for the sole benefit of the Participating Company. UCA-IL shall not be liable to any third party for any loss, liability, damage, or expense. Any modification or extension of this Participant Agreement shall not be binding on either party unless it is written and signed by both parties.

  3. No failure or delay by UCA-IL in exercising any right, power or privilege under this Participant Agreement shall operate as a waiver thereof, nor shall any single or partial exercise of any right, power or privilege preclude any other or further exercise of any other right, power or privilege.

  4. Neither this Participant Agreement, nor any of the rights, duties or obligations of the parties hereunder, may be transferred or assigned (by operation of law or otherwise) by any party hereto except as otherwise provided for in this Participant Agreement or with the prior written consent of the other party, such consent of the other party not to be unreasonably withheld.

  5. This Participant Agreement shall be binding upon the parties hereto and their respective successors in interest and assignment.

  6. This Participant Agreement only applies to the activities of the Participating Company in the State of Illinois, and it shall be governed by the laws of the State of Illinois.
IN WITNESS WHEREOF, the parties have caused the execution of this Participant Agreement in their behalf by the undersigned duly authorized person.
 
Safety Alliance, LTD.
UCA-IL’s Safety Administrator


By:_____________________________________

Print
Name:__________________________________

Title:___________________________________

Date:___________________________________
 
Participating Company



By:____________________________________

Print
Name:__________________________________

Title:___________________________________

Date:___________________________________
 
 
 
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