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Request for Quotation (RFQ)_Supply and Delivery of Goats and Sheep for the Partnership for Resilient and Inclusive Small Livestock Markets (PRISM) Project

Heifer International Rwanda

Heifer International Rwanda (HIR) is a Nonprofit and International Non-governmental Organization with the mission to alleviate hunger and poverty, while caring for the environment through sustainable agricultural practices. In collaboration with the Government of Rwanda and other relevant partners, this project has now grown to cover the whole country to become the flagship program known as “one cow per poor family”.

 

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REQUEST FOR QUOTATION 

RFQ Reference No. HPI20261002RW

SUPPLY AND DELIVERY OF GOATS AND SHEEP FOR THE PARTNERSHIP FOR RESILIENT AND INCLUSIVE SMALL LIVESTOCK MARKETS (PRISM) PROJECT.

Three lots: For Goats & Sheep.
RFQ Release Date:  5th October 2026
Question/ Inquiry Submission Deadline:  23rd October 2026
Quotation Submission Deadline:  29th October 2026
Selection Committee review  5th November 2026
Notification of award  13th November 2026
Award agreement negotiation and signing  27th November 2026
Electronic submission to the attention of:  Heifer International Rwanda
Electronic submission:  procurement-rw@heifer.org
Contact information for inquiries about this RFQ: procurement-rw@heifer.org

1. BACKGROUND 

Heifer International Rwanda (HIR) is a Nonprofit and International Non-governmental Organization with the mission to alleviate hunger and poverty, while caring for the environment through sustainable agricultural practices. In collaboration with the Government of Rwanda and other relevant partners, this project has now grown to cover the whole country to become the flagship program known as “one cow per poor family”.

Heifer International Rwanda projects focus on improving income and nutritional status, mobilizing farmers, and promoting local capacity through training of project participants, promoting market linkages for dairy value chain actors, improving the quality of livestock through artificial insemination services, empowering rural women, building resilience through sustainable agricultural practices, and connecting local communities to business development services.

Heifer International Rwanda partners with smallholder farmers to build sustainable livelihoods by empowering them to use their own energy, ingenuity, and dreams to fuel their success out of hunger and poverty. Heifer programs mobilize communities and foster the organization of associations, cooperatives and social networks while strengthening their capacity to address development challenges. 

2. Objective and scope of supply. 

The objective of this procurement is to obtain the required quantities of livestock, meeting the prescribed technical and quality standards, and to deliver them to the designated locations in Rwanda’s Northern, Southern, and Western Provinces. 

To facilitate sourcing, evaluation, delivery, and contract management, the procurement is divided into the following three (3) lots: 

Lot  Livestock required  Delivery Province
Lot 1  Goats and sheep  Northern Province
Lot 2  Goats and sheep  Western Province
Lot 3  Goats  Southern Province

A bidder may submit a quotation for one or more lots, depending on its technical, financial, and delivery capacity but may be awarded a maximum of two (2) lots. Each lot will be evaluated independently. 

Transport, unload and hand over the animals at every designated delivery location in Annex 1 at the supplier’s cost and risk. Replace, at no additional cost, any animal rejected during inspection or found not to comply with the contract. Coordinate deliveries with HIR/PRISM and obtain signed delivery notes and acceptance records for each location.

3. Mandatory Administrative Requirements. 

Each quotation must include the following valid documents: 

  1. Company registration certificate or applicable business license issued by the Rwanda Development Board (RDB). 
  2. Tax Clearance Certificate issued by the Rwanda Revenue Authority (RRA). 
  3. Latest Corporate Income Tax Declaration issued by or submitted to RRA. 
  4. Certificate of Good Standing or Non-Bankruptcy Certificate issued by RDB. 
  5. Rwanda Social Security Board (RSSB) Clearance Certificate. 

Failure to submit any mandatory administrative document, or submission of an invalid or materially incomplete document, will result in the quotation being declared non-responsive and excluded from further evaluation. 

4. Mandatory technical specifications. 

Technical specifications for goats and sheep

All animals supplied must meet the applicable minimum technical specifications set out below. 

4.1 Technical Specifications for goats 

➢ Female local goats must be in reproductive age with a weight ranging from 15-18 Kgs; 

➢ The male goats (bucks) must be crossbreeds between local goats and Gala or Boer goats with at least 20 Kgs of body weight and with a minimum blood level of at least 50%; 

➢ Female goats must be aged between 10-12 months while male goats must be aged between 12-15 months.

➢ Goats should have no phenotypic and/or anatomical defect(s)

➢ Each goat shall wear a clearly visible ear-tag recognized by the competent authority in Rwanda. 

➢ Preferably, goats will originate from the same district as the farmers’ district of residence. The sourcing of goats from a different district must be approved by Heifer International Rwanda.

4.2 Technical specifications for sheep 

➢ Female sheep must be cross between merinos and local sheep in reproductive age, weighing between 16-20 Kgs and be aged between 10-12 months. 

➢ Male sheep must weigh at least 25 Kgs and be aged between 12-15 months for optimal reproductive capability.

➢ Male sheep must be crosses of Merinos with a minimum bloodline of 50%. ➢ Sheep must be free from any phenotypic or anatomical defects. 

➢ Each sheep shall wear a clearly visible ear-tag recognized by the competent authority in Rwanda. 

➢ Preferably, sheep shall originate from the same district as the farmers’ district of residence. The sourcing of sheep from a different district must be approved by Heifer International Rwanda.

5. Health Requirements

All animals supplied must meet the health requirements set out below and the bidder shall submit the signed Declaration of Compliance in Annex 2. 

5.1 Health Requirements for Goats and Sheep 

➢ Goats and sheep shall originate from areas which are officially free from Foot and Mouth Disease (FMD), Peste des Petits Ruminants (PPR) and Contagious Ecthyma. 

➢ Selected goats and sheep will be tested for brucellosis and Peste des Petits Ruminants (PPR) and shall test negative before their distribution. 

➢ Goats and sheep shall originate from farms and areas where no veterinary restrictions applicable to the species are enforced.

➢ Goats and sheep shall have been in quarantine/isolation during 5 days before their delivery.

➢ Goats and sheep shall be treated with acaricides for external parasites, anti-stress and a broad-spectrum anthelminthic against internal parasites prior to their delivery. 

➢ During quarantine and on the day of departure, the goats and sheep shall be inspected and found to be free from any sign of infectious or contagious diseases and external parasites;

➢ Goats and sheep shall not exhibit any genetic or other anatomical defect(s); 

➢ All goats and sheep tested negative to PPR shall be vaccinated against PPR before their distribution. 

➢ Goats and sheep shall be insured by the Vendor before their placement. 

6. Technical requirements - Bidder Capacity and Supporting Evidence. 

The bidder shall provide: 

  1. A detailed description of the proposed livestock, including breed and quality
  2. At least three (3) certificates of satisfactory completion for contracts involving the supply of livestock or an equivalent initiative during the past five (5) years. Each certificate must be supported by the corresponding contract or purchase order and demonstrate experience with assignments of a similar nature and value.
  3. The bidder shall provide evidence of access to a credit line of at least: 
  • Lot 1: RWF 50 million 
  • Lot 2: RWF 55 million 
  • Lot 3: RWF 40million 

Where a bidder submits quotations for more than one lot, a single credit facility may be accepted, provided that its value meets or exceeds the combined financial-capacity requirement for all the lots quoted. The evidence must be current, valid, verifiable, and issued by a licensed financial institution in the bidder’s name. 

  1. A detailed selection and distribution plan showing the proposed sourcing locations, selection frequency, expected number of qualifying animals, delivery sequence, and ability to complete delivery within two (2) months of contract award. 
  2. A risk-mitigation plan addressing, at a minimum, animal illness, injury or death during transportation; shortages of qualifying animals; transport delays; and other circumstances that could affect timely delivery. 
  3. The signed Bidder's Commitment Letter in Annex 1. 
  4. The signed Bidder's Declaration of Compliance in Annex 2. 

Failure to meet any mandatory technical requirement or submit either signed declaration will result in the quotation being declared non-responsive and excluded from further evaluation. 

7. Delivery and Inspection Requirements 

  1. The successful supplier shall deliver all awarded livestock to the designated locations within a maximum of two (2) months from the date of contract award, in accordance with the approved delivery schedule. 
  2. The animals shall be delivered in good health, meet all contractual specifications, and be free from any third-party ownership claim, or other legal or financial claim. 
  3. HIR and the PRISM project team may inspect, test, and validate the animals and supporting records before acceptance. 
  4. Once an animal has been selected and validated by the PRISM project team, the supplier shall not substitute it without HIR's prior written approval. An unauthorized substitution may result in rejection of the affected animals, suspension of the selection exercise, or termination of the contract.
  5. The supplier shall present only animals that meet the requirements of this RFQ. If ineligible animals are presented for inspection, HIR may require the supplier to reimburse the reasonable costs of the unsuccessful selection visit and provide a written corrective-action commitment. 
  6. The successful bidder shall provide a performance guarantee equal to ten per cent (10%) of the contract price before contract signature. 
  7. A successful bidder requesting an advance payment shall submit an advance payment guarantee equal to the amount requested. The advance payment shall not exceed twenty per cent (20%) of the total contract price. The guarantee must be issued by a recognized financial institution acceptable to Heifer International Rwanda and remain valid until the advance payment has been fully recovered. 

8. Quantity of Animals and Delivery Locations 

This section specifies the type and number of animals required under each lot and the locations where the successful bidder must deliver them. Bidders must quote for the complete quantity under the lot or lots selected and ensure delivery to the stated locations within the required timeframe. 

The quoted price must include all costs associated with transportation, loading, offloading, animal handling, required veterinary inspections and documentation, insurance, and any other expenses necessary to deliver healthy animals that meet the required technical specifications. 

8.1 Quantity of Animals per Lot.

SN  Districts  Total HHs  Does  Bucks  Total Goats
LOT 1: Northern Province (Goats)
1  Gakenke  219  424  14  438
2  Burera  54  104  4  108
3  Gicumbi  181  350  12  362
4  Rulindo  196  379  13  392
5  Musanze  120  232  8  240
Total 1  770  1,489  51  1,540
LOT 1: Northern Province (Sheep)
1  Burera  114  220  8  228
2  Gakenke  64  123  5  128
3  Gicumbi  93  180  6  186
4  Musanze  44  85  3  88

Total 1 315 608 22 630 

LOT 2: Western Province (Goats)
1  Ngororero  288  558  18  576
2  Karongi  95  183  7  190
3  Nyamasheke  269  521  17  538
4  Rutsiro  0  0  0  0
5  Nyabihu  61  118  4  122
Total 2  713  1,380  46  1,426
LOT 2: Western Province (Sheep)
1  Nyabihu  145  280  10  290
2  Rutsiro  109  211  7  218
Total 2  254  491  17  508
LOT 3: Southern Province (Goats)
1  Nyaruguru  96  186  6  192
2  Nyamagabe  148  286  10  296
3  Huye  56  108  4  112
4  Ruhango  136  263  9  272
5  Gisagara  96  185  7  192
Total 3  532  1,028  36  1,064

8.2 Quantity of Goats to be Delivered by Sectors

District  Sectors  Delivery Location  Total HHs  Female goats  Bucks  Total goats
Northern Province
Burera Cyanika  Cyanika Sector office & Nyagahinga Cell Office  27  52  2  54
Gahunga  Gahunga Sector office & Kidakama Cell Office  27  52  2  54
Sub-total  54  104  4  108
Gakenke Busengo  Butereri  35  68  2  70
Busengo  Byibuhiro  28  54  2  56
Gashenyi  Taba  41  82  2  82
Gashenyi  Rukura  35  68  2  70
Kamubuga  Gaheri center  31  60  2  62
Kivuruga  Gasiza  22  40  2  44
Karambo  Kirebe  27  52  2  54
Sub-total  219  424  14  438
Gicumbi  Rwamiko  Rwamiko sector office  62  120  4  124
Nyamiyaga  Nyamiayaga Sector Office  68  131  5  136
Byumba  Gicumbi Stadium  51  99  3  102
Sub-total  181  350  12  362
Musanze  Rwaza  Rwaza Sector office  60  116  4  120

Remera Remera sector Office 60 116 4 120

Sub-total  120  232  8  240
Rulindo  Kisaro  Kisaro Sector Office  30  58  2  60
Burega  Burega Sector Office  30  58  2  60
Bushoki  Bushoki Sector Office  44  85  3  88
Murambi  Murambi Office  30  58  2  60
Cyungo  Cyungo Office  62  120  4  124
Sub-total  196  379  13  392
Total  770 1,489  51  1,540 
Southern Province
Ruhango  Bweramana  Rubona Cell Office  70  136  4  140
Byimana  Mahembe cell Office  17  33  1  34
Kabagari  Rwoga Cell Office  20  38  2  40
Ruhango  Buhoro Cell Office  29  56  2  58
Sub-total  136  263  9  272
Huye  Ruhashya  Muhororo Cell Office  20  39  1  40
Rwaniro  Mwendo Cell Office  36  69  3  72
Sub-total  56  108  4  112
Gisagara  Kigembe  Kigembe sector office  65  126  4  130
Gishubi  Gishubi sector office  10  19  1  20
Muganza  Cyumba and Saga cells  21  40  2  42
Sub-total  96  185  7  192
Nyaruguru  Busanze  Kirarangombe Cell Office  32  62  2  64
Kibeho  Kibeho Cell Office  32  62  2  64
Rusenge  Bunge Cell Office  32  62  2  64
Sub-total  96  186  6  192
Nyamagabe  Kitabi  Uwingugu Cell Office  82  158  6  164
Uwinkingi  Gahira Cell Office  66  128  4  132
Sub-total  148  286  10  296
Total  532  1028  36  1064
Western Province
Nyabihu  Mulinga  Gisizi Cell Office  37  72  2  74
Jomba  Guriro cell office  24  46  2  48
Sub-total  61  118  4  122
Ngororero  Matyazo  Gitega cell office  70  136  4  140
Kageyo  Kageshi cell office  80  155  5  160
Kavumu  Nyamugeyo cell office  50  97  3  100
Bwira  Bungwe cell office  44  85  3  88
Nyange  Bambiro cell office  44  85  3  88
Sub-total  288  558  18  576
Karongi  Murambi  Nkoton Centre  23  44  2  46
Murundi  Kamina Cell Office  18  35  1  36
Gashari  Gashari Sector Office  17  33  1  34
Mutuntu  Mutuntu Sector Office  23  44  2  46
Ruganda  Ruganda Sector Office  14  27  1  28

Sub total 95 183 7 190 

Nyamasheke Cyato  Rugali cell office  42  81  3  84
Gihombo  Gitwa cell office  83  161  5  166
Kirimbi  Nyarusange cell office  65  126  4  130
Kirimbi  Karengera cell office  16  31  1  32
Rangiro  Banda centre  20  39  1  40
Rangiro  Gakenke cell office  43  83  3  86
Sub total  269  521  17  538
Total 3  713 1,380  46  1,426 

8.2 Quantity of Sheep to be Delivered by Sectors

District  Sectors  Delivery Location  Total HHs  Female sheep  Rams  Total sheep
Northern Province
Burera Kivuye  Kivuye Sector Office  24  46  2  48
Rusarabuye  Rusarabuye Sector Office  32  62  2  64
Rugengabali  Rugengabali Sector Office  28  54  2  56
Cyanika  Cyanika Sector office & Nyagahinga Cell Office  15  29  1  30
Gahunga  Gahunga Sector office & Kidakama Cell Office  15  29  1  30
Sub-total  114  220  8  228
Musanze  Musanze  Musanze sector Office  44  85  3  88
Sub-total  44  85  3  88
Gakenke Busengo  Butereri  1  2  0  2
Busengo  Byibuhiro  1  2  0  2
Gashenyi  Taba cell office  5  9  1  10
Kamubuga  Sector office  54  105  3  108
Kivuruga  Gasiza  3  5  1  6
Sub-total  64  123  5  128
Gicumbi Miyove  Miyove Cell office  52  100  4  104
Manyagiro  Nyiragifumba Cell office  41  80  2  82
Sub-total  93  180  6  186
Total  315  608  22  630
Western Province
Nyabihu Rurembo  Rwaza cell office  65  126  4  130
Kintobo  Kintobo sector office  55  106  4  110
Rambura  Guriro cell office  25  48  2  50
Sub-total  145  280  10  290
Rutsiro  Kivumu  Nganzo Cell Office  20  39  1  40
Manihira  Manihira Sector Office  15  29  1  30

Mukura Nyaburama (MINAGRI

House) 25 48 2 50 

Nyabirasi  Ngoma Cell Office  34  66  2  68
Rusebeya  Rusebeya Sector Office  15  29  1  30
Sub-total  109  211  7  218
Total 2  254  491  17  508

5. Instructions to bidders 

Submit the technical proposal and financial quotation as two separate PDF files, both clearly marked with the RFQ number and bidder’s name. Submissions made through external links will not be accepted. All required documents must be submitted as attachments. 

Send the quotation electronically to procurement-rw@heifer.org using the subject: “RFQ HPI20261002RW – Supply and Delivery of Goats and Sheep for PRISM Project” and submitted by 29th October 2026 at 5:00pm Kigali time. 

Quote in Rwandan Francs (RWF). Prices must include all applicable taxes, loading, transport, offloading and every cost required for complete performance. 

The quotation must remain valid for 60 calendar days from the submission deadline. 

All forms and declarations must be completed and signed by an authorized representative. Pages should be numbered and reference the bidder and RFQ number. 

Late quotations will not be considered. Bidders are responsible for ensuring that complete files are received before the deadline. 

Questions must be sent to procurement-rw@heifer.org by the inquiry deadline. Information obtained from any other source is not official.

6. Mandatory administrative requirements – Pass/Fail

Administrative compliance will be assessed on a conformity-to-requirement basis. A bidder must pass every mandatory requirement below. Failure to submit a mandatory document, or submission of an invalid, unsigned or materially incomplete document, will result in the quotation being declared non-responsive and excluded from further evaluation.

Ref.  Mandatory requirement  Pass  Fail
A1 Quotation received by the deadline, in the prescribed electronic format and with separate technical and financial PDF files.
A2  Valid RDB certificate of domestic company registration/registration document
A3  Valid RRA tax clearance certificate
A4 Most recent corporate income tax declaration acknowledged by RRA
A5 Valid RDB certificate of good standing/non-bankruptcy certificate
A6  Valid RSSB clearance certificate
A7  Signed quotation and completed Bidder Declaration in Form 1

7. Mandatory technical evaluation – Pass/Fail

Only administratively compliant quotations will proceed with technical evaluation. Technical compliance will be assessed on a conformity-to-requirement basis. The bidder must pass every mandatory technical criterion. Failure to meet any specification, quantity, delivery or evidence requirement will result in the quotation being declared technically non-responsive and excluded from financial evaluation.

Ref.  Mandatory criterion  Pass  Fail
T1 Full compliance with all minimum technical specifications applicable to each livestock category, as set out in Section 3.
T2  Signed Bidder’s Declaration confirming compliance with all applicable animal health requirements set out in Section 5.
T3 Submission of at least three satisfactory completion certificates, each supported by the corresponding contract or purchase order, demonstrating successful completion of assignments of a similar nature.
T4 Access to Credit: Submission of current, valid, and verifiable evidence, issued in the bidder’s name by a licensed financial institution, confirming access to a credit line of at least the minimum amount required for each quoted lot.
T5 Detailed livestock selection and distribution plan for each quoted lot.
T6 Risk-Mitigation Plan: A clear and practical plan outlining appropriate mitigation actions and contingency measures for identified delivery risks.
T7 Signed confirmation that adequate insurance coverage will be provided for all livestock for 12 months from the date of placement with the beneficiaries.

8. Financial evaluation and award

Only quotations that pass all mandatory administrative, and technical compliance requirements will proceed to financial evaluation. The financial evaluation will be conducted separately for each lot and will be based on the total evaluated price, inclusive of all applicable taxes, insurance, fees, transportation, delivery and other related costs. Any arithmetic errors identified during the evaluation will be corrected in accordance with the provisions of this RFQ, and the affected bidder will be notified accordingly.

Subject to satisfactory verification of the bidder’s information, and agreement on contractual terms, the contract will be awarded to the responsive bidder offering the lowest evaluated total price and meeting all mandatory quality and delivery requirements

9. Contract conditions

The successful bidder shall provide a performance guarantee equal to 10% of the contract price before contract signature, in a form acceptable to HIR.

Payment will be made in accordance with the contract after satisfactory delivery and acceptance, receipt of valid invoices and all required supporting documents.

No substitution or change of specification is permitted without HIR’s prior written approval.HIR may reject, suspend or terminate performance for fraud, corruption, collusion, conflict of interest, material misrepresentation or breach of applicable safeguarding and ethical requirements.

This RFQ does not create an obligation to award a contract or reimburse any cost incurred by a bidder in preparing or submitting a quotation.

10. Intellectual Property

Section 1. Ownership Generally. Subject to Section 8.2 below, any intellectual property (including but not limited to copyrights, trademarks, service marks, and patents), intellectual property rights, deliverables, manuals, works, ideas, discoveries, inventions, products, writings, photographs, videos, drawings, lists, data, strategies, materials, processes, procedures, systems, programs, devices, operations, or information developed in whole or in part by or on behalf of Contractor or its employees or agents in connection with the Services and/or Goods (collectively, the “Work Product”) shall be the exclusive property of HPI. Upon request, Contractor shall sign all documents and take any and all actions necessary to confirm or perfect HPI’s exclusive ownership of the Work Product.

Section 2. Prior-Owned Intellectual Property. Any intellectual property owned by a Party prior to the Effective Date (“Prior-Owned IP”) shall remain that Party’s sole and exclusive property. Regarding any of Contractor’s Prior-Owned IP included in the Work Product, Contractor shall retain ownership, and hereby grants HPI a permanent, non-exclusive, royalty-free, worldwide, irrevocable right and license to use, copy, reproduce, publicly display, edit, revise, perform, and distribute said intellectual property, in any format or any medium, as part of the Work Product. 

Section 3. Work Made for Hire. To the extent copyright laws apply to the Work Product, the Parties agree that (a) HPI specially ordered or commissioned the Work Product, (b) the Work Product is a “work made for hire” under United States copyright laws, and (c) HPI shall be deemed the author thereof and shall own all right, title, and interest therein. To the extent such rights, in whole or in part, do not vest in HPI as a “work made for hire”, Contractor hereby irrevocably grants, assigns, and transfers to HPI, exclusively and in perpetuity, all of Contractor’s rights of any kind or nature, now known or hereafter devised, in, to, and in connection with the Work Product, and HPI shall solely and exclusively own any and all rights therein, and in the elements thereof, including but not limited to any and all allied, ancillary, subsidiary, incidental, and

adaptation rights. Contractor hereby waives any and all rights known as “moral rights”, and any similar rights, which Contractor may have in connection with the Work Product. The description of Services and/or Goods provided in this Agreement shall in no way limit the manner in which HPI may use the Work Product

Form 1 – Bidder information and commitment

Legal name of bidder
Registered address
RDB registration number
TIN
Authorized representative
Telephone and email
Bank/account name (for verification at contracting)

We certify that the information and documents submitted are true, complete and current. We confirm that our quotation is valid for 60 calendar days; includes all taxes, packaging, transport, loading and offloading costs; and offers quality animals. We accept the specifications, delivery obligations, inspection and replacement requirements stated in this RFQ. We declare that we have disclosed any actual or potential conflict of interest and that we have not engaged in fraud, corruption or collusion in connection with this procurement.

Name:  Title:
Signature:  Date:
Company stamp:  Official email:
Authorized representative’s confirmation: _______________________________________________

Annex 2: BIDDER’S DECLARATION OF COMPLIANCE FORMAT

Bidder’s Letterhead] 

Tender Reference No.: HPI20261002RW 

Tender Title: Supply and delivery of goats, and sheep for the partnership for resilient and inclusive small livestock markets (prism) project. 

I/We, the undersigned, duly authorized to represent [Bidder’s Company Name], declare that: 1. We have read and understood the technical specifications and the animal health and welfare requirements of this RFQ, and we confirm that we will fully comply with them. 2. We will source the required livestock only from areas that are not subject to veterinary restrictions arising from infectious disease outbreaks. 

  1. We will manage, handle, and transport all animals in accordance with applicable laws, regulatory requirements, and HPI's Animal Wellbeing Policy. 
  2. We will ensure humane and appropriate transportation conditions for all animals supplied. 
  3. We will cooperate with the competent authority or HIR representative in validating the health status of each delivered livestock fourteen (14) days after delivery. 6. We will provide all required certificates, permits, test results, insurance records, and veterinary documents as evidence of compliance. 
  4. We understand that failure to comply with a mandatory requirement may result in rejection of our quotation, rejection of the affected animals, or termination of the contract. 

We make this declaration in good faith and without reservations. 

Signed on behalf of: [Bidder’s Company Name] 

Authorized Representative: ____________________________ 

Name: ____________________________________________ 

Title/Position: ______________________________________ 

Signature: ___________________________________________________ Date: ___________________ 

Stamp/Seal: ___________________

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