City of Lewiston Finance Department - Allen Ward, Purchasing Agent
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City of Lewiston
Finance Department
Allen Ward, Purchasing Agent
27 Pine Street, Lewiston ME
207-513-3040
award@lewistonmaine.gov
2020-029
One (1) Single Axle Truck Cab & Chassis w/ Chassis Mounted Removable Sander
June 12, 2020
Sir/Madam:
Sealed bids will be received in the office of the Purchasing Agent on Tuesday, June 30, 2020 until 2:00
p.m. at which time they will be publicly opened and read aloud on the enclosed specifications for One (1)
Single Axle Truck Cab & Chassis w/ Chassis Mounted Removable Sander for the City of Lewiston
Department of Public Works, Highway Division.
The Finance Committee reserves the right to accept or reject any and all proposals.
Please use a sealed envelope clearly marked with the bid name and number when submitting your bid. Only
sealed bids will be accepted. Faxed bids will not be considered.
Sincerely,
Allen Ward
Purchasing Agent
ASW/mrrCITY OF LEWISTON, MAINE
DEPARTMENT OF PUBLIC WORKS
One (1) Single Axle Truck Cab & Chassis
w/ Chassis Mounted Removable Sander
Bid # 2020-029
Bid Date: Tuesday, June 30, 2020
The City of Lewiston is accepting sealed proposals for One (1) Single Axle Truck Cab & Chassis
w/ Chassis Mounted Removable 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, seasonally as a
water tanker in summer operations and sander during winter operations.
Bids will be received at the office of the Purchasing Agent until 2:00 p.m. on June 30, 2020, and
then, at said office, publicly opened and read aloud.
Each bidder is required to state in his/her Proposal his/her name and place of residence and the names
of all persons or parties interested as principals with him/her; and that the proposal is made without
any connection with any other bidder making any proposal for the same work; and that no person
acting for or employed by the City of Lewiston is directly or indirectly interested in the proposal or in
any contract which may be entered into to which the proposal relates, or in any portion of the profits
therefrom, except as provided by the City Charter.
The proposal must be signed by the bidder with his/her full name and address and be enclosed in a
sealed envelope. The sealed envelope shall be marked with the name and address of the bidder and
entitled:
PROPOSAL FOR
One (1) Single Axle Truck Cab & Chassis w/ Chassis Mounted Removable Sander
and addressed to: "Purchasing Agent, City Hall, Lewiston, Maine". If the proposal is forwarded by
mail, the sealed envelope containing the proposal and marked as above must be enclosed in a second
envelope which shall be addressed to: "Purchasing Agent, City Hall, 27 Pine Street, Lewiston, Maine
04240." All mailed proposals should be sent by registered mail to ensure delivery.
Any bidder may withdraw his/her proposal prior to the scheduled time for the opening of proposals
upon presentation to the Purchasing Agent of a request, in writing, to do so. Any bidder who
withdraws his/her proposal within thirty (30) days after the actual opening thereof shall be
considered to have abandoned his/her proposal. Any proposal received after the scheduled opening
time will not be considered.
The City reserves the right to negotiate with the low bidder to bring projects down to within budget.
The Finance Committee reserves the right to waive any formality and may consider as informal any
Proposal not prepared and submitted in accordance with these provisions. The Finance Committee
reserves the right to accept any Proposal or reject any or all Proposals if it is deemed to be in the
public interest to do so. In accordance with section 3.1.6.5 of the City of Lewiston Purchasing Policy,
The Finance Committee, upon recommendation of the Director or designee, shall have the authorityto reject any and all proposals when proposals are deemed non-responsive, token, collusive or
otherwise non-acceptable, and such action is in the best interest of the City.
Specifications can be obtained free of charge on the City of Lewiston web site under Finance Dept/Bids
and Awards (www.lewistonmaine.gov).
The following specification shall be minimum requirements and bid shall be of the manufacture’s
latest model and design. The bid item must also comply with applicable federal and Maine laws. All
items appearing in the bidder’s regular published specifications are assumed to be included in the
bidder’s proposal.
Public works must be satisfied that the Equipment Dealer maintains adequate parts and service
facilities to include a full shop and field service performed by factory trained mechanics within 75
mile radius of 103 Adams Ave Lewiston. Vendors outside this radius are excluded from
consideration due to time requirements to pick up parts and deliver units for service/ repairs.
Furnishing and mounting of all additional equipment shall be the responsibility of the Chassis bidder.
All additional equipment added to the unit will be appropriately matched to the machine. All
hydraulics and electrical components will be appropriately installed and secured, subject to approval
by a representative from the City of Lewiston.
The bid will be awarded based 4 factors. Each of these factors will be worth a certain percent value.
The values are as follow:
1. Total bid price including all options selected by the city 35%
2. Compliancy to the bid specification. 30%
3. Other Maine Municipalities experience with this exact make, model and 10%
application of machine that appears in the spec/Bid proposal.
4. Lewiston Public works experience/ history with equipment from this manufacture 25%
and the selling dealer. As well as how it effects the standardization of the fleet.
The above Item # 3: The dealer must supply in writing a list with contact information of other
municipalities within the state of Maine that have this Make, and Model machine. This machine must
be equipped and used in similar fashion as it would be used here at the City of Lewiston Maine.
Any Questions about the specification or to arrange to see the trade please call Phil Brienza @ 513-
3145.
Any exceptions to the bid must be clearly spelled out and attached to your bid proposal.
Bidder’s proposal shall include a complete build data sheet for unit purposed.
SPECIFICATIONS
Two (2) Single Axle 4x2 truck Chassis & Cab, Freightliner 108SD, International 7400 or approved
equal.
YES NO
MODEL Latest
YEAR 2020-2021
WHEEL BASE 180” (Approx. as required for sander body mounting)
C.A. 90” – 96” usable (approx. as required for sander body
mounting)G.V.W. 42,000 lbs. (min)
ROAD SPEED 70 MPH
CAB Conventional Cab w/ Air mounting and premium insulation
package.
Forward tilting hood, w/ access panels to service engine.
Full rear window in cab.
Side hood air intake with inside/outside air with snow door.
To have Switch w/ Indicator light, wiring and 2-Stainless
Steel Roof Mounting Brackets for strobe lights. One on
each side of the cab over doors.
Deluxe Drives seat, air suspended, high back, w/ air
lumbar support.
Deluxe Passenger seat, air suspended, high back, w/ air
lumbar support
Tinted glass, all around.
Full gauge package.
Hour meter.
Dual sun visors.
Adjustable (tilt-telescope) steering wheel.
Stainless steel entry steps on both sides of cab.
Reinforced roof for roof mounted components.
Snow shield over fresh air intake.
ENGINE DD8 7.7L 6 CYL min. 330 HP @ 2200 RPM, 2600 GOV
RPM, 1000 LB/FT @ 1200 RPM
H.D. cooling system, with air operated fan clutch.
Must have Min.2010 EPA/CARB Emissions Certification &
2008 CARB Emissions Certification for clean idle.
Right hand side vertical exhaust stack with stainless steel
shielding.
DPF exhaust component heat shielding to be stainless
steel. Cover should have access by way of cutouts, doors
or be positioned in such a manner as to not block access
to washing/ cleaning of these components.
Anti -freeze to – 34 F.
Min. 750 WATT/115 VOLT BLOCK HEATER w/ plastic
receptacle mounted under LH door.
Fuel/water separator.
Gates Blue stripe coolant hoses or equivalent.
Lower radiator guard.
TRANSMISSION Allison HD 3500RDS
6 – Speed
Push button dash controls.
Transmission to be filled with Synthetic Transmission fluid.
Heavy duty Transmission cooler.
Set up to run continuously engaged PTO. Left hand mount.
FRONT AXLE Set Back I beam type - 18,000 lb. Capacity (min).
18,000 lb. Capacity Flat leaf front suspension (min).
Shock absorbers.
STEERING Power Steering.
REAR AXLE 24,000 lb. Rear Axle Capacity (min).
24,000 lb. Capacity Flat Leaf Rear Suspension (min).Ratio: (geared for 70 MPH).
Driver controlled Traction Differential lock.
Warning Buzzer and Blinking Lamp with Mode switch for
Differential locking system when engaged.
Differential to unlock when ignition is turned off.
Differential to be filled with Synthetic rear end lube.
Right Rear leaf added to spring to level the truck (if
required in the opinion of the representative of the city).
DRIVELINE Meritor 18N Extended Lube Driveline or approved equal.
BRAKES ABS Air brake System.
Cam type brakes front and rear.
Front brakes 16 ½” x 5”.
Rear brakes 16 ½” x 7”.
Spring applied parking brakes.
Forward or high mounted rear axle brake chambers.
20 CFM air compressor (min).
Automatic ejection valves, with heater.
Bendix air dryer, with heater and screw on cartridge.
Mounted on passenger’s side of the chassis.
Aluminum Air Tanks W/ pull cables at all reservoirs.
Backing plates on all axles.
Automatic slack adjusters with stainless steel clevis pins.
FRAME 120,000 P.S.I. steel (min)
Section modules of 21.6 (min)
R.B.M. of 2,592,000 (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
36” 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.
Single channel frame rails
ELECTRICAL SEE ELECTRICAL REQUIRMENTS AT END OF SPEC
Full instrumentation package, Oil pressure, Coolant and
Transmission temperature, Fuel/DEF Fluid, Engine hours,
Voltage and Clock display.
All wiring and Cables to have wire loom (or equal) covering
over it.
12 Volt Electrical system.
2 Group 31 Batteries with min. total of 2250 CCA.
Battery box to have plastic or aluminum cover.
Battery box to have remote jump start posts.
Wire ground return for battery cables W/ extras frame
ground return.
Positive load disconnect in cab by driver’s seat.
160 Amp alternator (min).
6 Factory installed dash mounted accessory switches, w/
wiring, fuses and relays.
12 volt power supply as well as min. 1 USB 2.1 amp
charger on dash.
Dash mounted PTO switch indicator lamp.Junction Box to be installed at the end of the wiring for the
6 dash mounted switch harness, in the cab.
Junction Box to have terminal strips W/6 studs for power at
the end of the wiring as well as a grounding stud wired to
handle the total load of all circuits. Box preferably left
loose between seats. (1) 30 amp marked Sander power. &
(5) 20 Amp Labeled, Rear Strobe light, Sander lights,
Camera system, 2-way Radio, Fog lights.
Electronic warning system, sounding when Park brake not
applied and cab door is opened.
Enhanced Interior dome lighting.
Heated windshield.
AM-FM Blue tooth dash mounted radio. To include one
touch phone usage.
Auxiliary Cab side mounted directional lamps.
Cab marker lights.
Dual electric horns.
Intermittent wipers w/ delay programmed to slow speed
when P/brake is on.
Wired with a feed for ground speed sander control.
To have Switch, Wiring, Indicator light and Stainless Steel
Roof Mounting Brackets for strobe lights one on each side
of the cab.
2 – Whelen Super LED Beacons part # L31HAF installed
on the chassis dealer supplied Aluminum / Stainless steel
cab mounts.
Beacons to have the optional branch Guard Whelen Part #
L360BGB installed.
Back up Alarm 95 DB min.
7-Pin plastic RV type trailer plug to end of frame to be
installed in hitch plate.
7-Pin RV type trailer plug mounted at back of cab to supply
electrical light feeds for sander body( Marker, Directional,
Reverse lights and ground).
FUEL TANK 50 gallon Aluminum tank w/ stainless steel steps and
stainless steel mounting straps.
Left hand mount.
DEF tank appropriately sized to fuel tank. Left hand mount,
beside fuel tank. To have magnetic misfiling prevention
device installed in the filler neck.
WHEELS Front 22.5” X 9.00”
Rear 8.25” x 22.5”
10 Hole disc , Hub Pilot, heavy duty Aluminum rims
Matching Spare wheel and Tire with Max Traction tread for
both front and rear axles.
TIRES Front: 315/80R22.5 20 Ply (H)
Max Traction tread
Rear: 11R22.5 16 Ply (H)
Max Traction tread
MISCELLANEOUS Mirrors, West Coast 6x16 heated
Left and Right hand fender mounted stainless steel heated
spot mirrors.2.5” Rubber fender extensions.
Exterior and Interior grab handles both sides of cab.
Heavy duty 3 piece Front bumper W. collapsible ends.
Wet type wheel seals (front).
Horizontal muffler w/ vertical stack right side.
Air conditioning.
Air Horns.
2-1/2 pound fire extinguisher and reflective triangles -
Shipped loose.
Front tow hooks.
Door and ignition keyed alike min 4 sets of full function
keys.
PAINT Yellow Cab.
Black Frame.
EXTENDED 3 YEARS DETROIT CONNECT BASE PACKAGE
WARRANTY/ (VIRTUAL TECHNICIAN, DETROIT CONNECT PORTAL
SERVICES ACCESS)
5 Year Engine and Transmission Warranty
Reverse Mounted Sander w/ Cross Conveyor
SANDER BODY SEE ELECTRICAL REQUIREMENTS AT END OF SPEC
ELECTRICAL All add on Electronic Accessory components are to get
power from cab manufactures supplied junction box in
cab. Only electrical accessories that exceed the capacity
of the supplied circuits can be feed from other locations.
The junction box is to pick up power only; for anything that
should be in an enclosure, the enclosure will be supplied
by the vender installing that component. (TBD by City
representative).
Truck Light (# 50400) junction box(s) and corresponding
fittings to be used on all wiring and at all fixtures and
boxes. Weather pack plug will be used at all light fixture
junction points and as needed were the truck light fittings
will not be practical to use.
Led Lighting package wherever available.
Unprotected coiled up wiring on cab floor is not
acceptable. This wiring will need to be housed in an
enclosure secured out of the way. (TBD by City
representative.
A 7 Pole RV type plug to connect to trailer socket.
Two Oval Grote LED Directionals (Grote 53962), two
back-up lights (Grote 62561) and Two LED Oval Strobes
(Grote # 77363) to be mounted in stainless steel
enclosures mounted high on to the sander body.
Two Amber LED utility lights (Truck Star Light # 1492116)
to be mounted on the sander to illuminate the sander
discharge tied into the dash switch marked sander light.
Exact location to be determined.
Two Amber LED utility lights (Truck Star Light # 1492116)
mounted on the mirror brackets forward facing exactlocation to be determined. Light to be tied into dash switch
marked fog or driving lights.
Two Clear LED flood lights (Truck Star # 1492115)
mounted on rear of truck tied into the back up light circuit.
Exact location to be determined.
All electrical components are to be shielded from damage
either by enclosure or wire protection.
All wiring and Cables to have wire loom (or equal)
covering.
Truck Star Part # 8883000 back up camera system
installed.
Camera system to have second camera mounted and
aimed at the sander body/conveyor showing conveyor
and sand moving out of body and spinner rotation. Exact
location to be determined.
HYDRAULICS Hot Shot type PTO W/ hydraulic pump, pump to be
constant driven off transmission even when vehicle is
stopped. PTO with auto shutdown for low hydraulic oil.
Hydraulic system to have quick coupler for the quick
removal and installation of the Spinner and Sander body.
All quick coupler connections shall be stainless steel and
have caps for off season storage.
Cirus control system and Valve Body W/ Stainless Steel
Valve body Enclosure and Hydraulic Tank. To be mounted
on Passenger side of truck. Valve body cabinet to be
easily accessible not requiring the use of tools.
Stainless steel hydraulic lines and Hydraulic quick
couplers were ever possible.
SANDER BODY 10' long Min. 6 yard capacity 304 Stainless steel front
discharging Sander body 3/16” stainless steel (min)
Main conveyors to be stainless steel with AR 450 wear
plate under conveyor chain. Conveyor Min 18” Wide and
to have Min. 3/8” thick Heavy duty conveyor chain flights.
Stainless steel heavy duty cross conveyor.
Hydraulically driven Poly Spinner mounted in such a way
to allow movement in all directions to change position of
spinner to adjust spread pattern.
Stainless steel drop chute.
Sander Body sub-frame to have ¼” thick heavy-duty
stainless steel channel Iron cross members. (Not formed
channel iron cross members)
Heavy duty Galvanized 4 section hinged top screen.
Extended grease lines to side of sander for ease of
service for all bearings. (Rubber W/ corrosion resistant
fittings or stainless steel lines)
Hydraulically driven liquid calcium pumping system.
System to have adjustable flow rates for the calcium from
approximately 2GPM up to 10 GPM.
Calcium to be applied at the drop chute.
Stainless steel reinforced shelf running the length of the
sander body for the calcium tanks that will sit on.Sander to have lifting points capable of lifting sander with
calcium tanks loaded. Lifting points to be at all four
corners of the top of the sander body.
Oval LED Directional, Running and back up lights to be
high mounted on sander body in stainless steel boxes,
exact location to be determined.
Truck Light # 50400 junction box(s) and corresponding
fittings to be used for all electrical installations on sander.
Sander to be mounted in such a way it can be Quickly
and easily removed and installed.
All electrical and hydraulics connections to be quick
connecting with caps for off season storage. Hydraulic
quick couplers to be stainless steel.
Heavy duty 3/8” thick conveyor chain flights every other
link.
12” Stainless steel spill shields mounted on the front and
rear of the body.
Extended grease lines to Sides / Rear of sander for ease
of service.
2” drive shaft and 1 ¼” Idler shaft. Min.
Spring loaded front Idler assembly.
Center Idler shaft and sprockets.
MISCELLANEOUS Stainless steel chock block holder installed on front drivers
side of body to hold 2 Buyers WC1086 rubber chock
blocks. Exact location to be determined.
Stainless steel Shovel holder capable of holding 1- square
blade D-handled shovel mounted to the front of the sander
body. Holder to suspend shovel from hitting body or have
a stainless steel plate at the point of contact with the body.
Exact location to be determined.
Replicable Full plastic wheel well tubs over rear tires. Min
of 4” of clearance between tires and plastic wheel wells.
Mud flaps front and rear of rear tires W/ stainless steel
anti-sail brackets.
Fold down stainless steel ladder mounted to left side of
body near front of body exact location TBD.
HITCH PLATE Heavy Duty trailer hitch plate Min 3/4” steel welded to rear
of truck.
15-Ton forged swivel-type pintle hook installed in plate.
2-Welded forged on ¾”D-Rings.
Seven pin RV type trailer plug to be installed in plate.
Primary Rear view camera to be mounted with deflector
shield to protect camera.
SANDER Control system to have ground speed sander controls for
CONTROLS liquid and granular.
Truck to have Drive – By Downloading system compatible
with the system presently in place at the city.
Control system to be Cirus Spread Smart Model RX (NO
Substitutions)
Vehicles to use wired ground speed not GPS.
Unit to have road ranger type temp sensor tied in to Cirus
system.TRAINING To be held at LPW yard 103 Adams Ave Lewiston
by a factory trained representative.
MANUALS Two complete sets of parts, service, and repair manuals.
SERVICE & The Public Works department must be satisfied that the equipment
INSTALLATION dealer maintains adequate service, installation and parts facilities, with
full shop and field services capabilities performed by factory trained
mechanics. Within 75 mile radius of the 103 Adams Ave. Facility.
TRADE Unit # 121 2008 GMC TC8C04 Sander truck. Sander body goes with the
truck the water tank set up is not included with the trade.
VIN# 1GDP8C1B88F402880
Mileage – 88370 + as of 6/15/20
ELECTRICAL REQUIREMENTS
The following will be considered the minimal required to meet this part of the specification. Any
changes to the following spec will need approval from a representative of the City of Lewiston.
1. All up-fitter electrical circuits will be fed by the chassis supplied up-fitter switches, wiring and
distribution box. Exceptions would be circuits with an electrical load that exceeds the
capabilities of the up-fitters electrical distribution system. The electrically driven tarp system
would be an example of one of these circuits. With the approval of a representative of the
City of Lewiston multiple electrical items may be tied into the same circuit.
2. Every circuit will be one continuous solid colored wire, splicing is not acceptable.
3. All up-fitters wiring will have one common point of origin in the cab. These wires will start in a
junction box in the cab (up-fitters power distribution box), located at the termination of the
chassis dealer supplied up-fitter switches wiring harness. Exact location of the up-fitters
power distribution box TBD.
4. Ground stud/s in the up-fitters power distribution box capable of handling the total electrical
load of all circuits located in this box. The ground/s will be wired directly to the negative
terminal of the battery.
5. All Wiring from the chassis up-fitters power distribution box, must be shielded inside conduit
or flexible wire loom.
6. Wiring in the case of sanders/ dump bodies that will require long runs of multiple wire to a
common area of the truck, will be in the form of multiple conductor rubber coated trailer cord
or individually color coded wires shielded inside a conduit or flexible wire loom. These cables
will start at the up-fitters power distribution box and end at ether a truck light 50800 or 50600
weather resistant electrical junction box. The appropriate truck light 3 piece fittings for the
size and type of wiring used, must be used. Silicone or other substances cannot be used in
place of the correct fittings.
7. All wiring, conduit and flexible wire loom will be secured/ supported in place a minimum of
every 16”, By way of heavy duty vinyl coated wire & tube bolt on clips were ever possible and
heavy duty cable ties W/ steel locking barb wherever the heavy duty vinyl coated wire & tube
clamps cannot be used.
8. All electrical fixtures and devices are to have both power and ground wires beginning at the
chassis up-fitters power distribution box.
9. All up-fitter installed flood, spot, back-up flood lights and area lighting will be weather pack
type connectors with the required number of terminals for all wiring of that fixture. Power,
Ground etc.
10. Any connections outside the cab of the vehicle will be treated as follows:Two wires being connected together
Both wires being connected shall be striped
back approx. 3/4”
A heat shrink solder connector is slid on to
one of the wire.
Wires shall then be twisted together retaining
a straight line with the rest of the wire.
The heat shrink connector is then slid back
over the bare twisted section of the wire
The connector is then heated until solder/
heat shrink is properly melted into place.
Crimped on type Terminals being installed on the end of a wire
Heat shrink is required on all crimp on type connectors located outside the cab.
Wire will be stripped back as required by the connector manufacture.
The appropriate heat shrink but connector shall be installed with the appropriate
crimping tool to assure the heat shrink is not damaged in anyway.
ANY QUESTIONS REGAURDING THE WIRING OR INSTALLATION OF ANY OTHER
COMPONENTS OF VEHICLES AND EQUIPMENT FOR THE CITY OF LEWISTON MAINE SHALL
BE DIRECTED TO THE FLEET OPERATIONS MANAGER PHILIP BRIENZA @ 207-513-3145CITY OF LEWISTON, MAINE
BID #: 2020-029
One (1) Single Axle Truck Cab & Chassis w/ Chassis Mounted Removable Sander
PROPOSAL FORM
To receive consideration, the Proposal Form must be filled in and signed.
The undersigned hereby declares that he has carefully examined the specifications and that he/she
proposes and agrees, if this proposal is accepted, to provide the items identified in his/her proposal in
accordance with the specifications listed; and that he/she will accept full payment therefor the following
sum:
The bid will be awarded based 4 factors. Each of these factors will be worth a certain percent value.
The values are as follow:
1. Total bid price including all options selected by the city 35%
2. Compliancy to the bid specification. 30%
3. Other Maine Municipalities experience with this exact make, model and 10%
application of machine that appears in the spec/Bid proposal.
4. Lewiston Public works experience/ history with equipment from this manufacture 25%
and the selling dealer. As well as how it effects the standardization of the fleet.
The above Item # 3: The dealer must supply in writing a list with contact information of other
municipalities within the state of Maine that have this Make, and Model machine. This machine must
be equipped and used in similar fashion as it would be used here at the City of Lewiston Maine.
MAKE/MODEL
YEAR
1. One (1) Single Axle Truck Cab & Chassis $
2. Chassis Mounted Removable Sander $
3. Trade: Unit # 121 2008 GMC TC8C04 Sander $
Truck
VIN# 1GDP8C1B88F402880
TOTAL BID PRICE: (Items 1 - 2 Less Item 3) $
SERVICE SOFTWARE The following Items shall be priced separately.
SUPPORT / TRAINING
1. Engine Diagnostic Software $_________
2. Allison Transmission software. $_________
3. Communications Cable for electronic diagnostics. $_________
4. Vehicle Diagnostic and Repair Training to include
engine, transmission, and computer laptop
diagnostics tool training (8 Hrs. Min. for each of the $_________
two shifts.
5. Allison Mechanics tips guide, Trouble shooting and $_________
service manuals.Warranty: Cab and Chassis Warranty: Chassis Mounted Removable Sander Delivery Terms FIRM TAX ID/ DUNS # SIGNED BY PRINTED OR TYPED NAME PRINTED OR TYPED TITLE ADDRESS E-MAIL ADDRESS TELEPHONE # DATE
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