Museum of Idaho
RFQ: CM/GC Services Museum of Idaho Expansion
April 13, 2017
Museum of Idaho (MOI) will accept qualifications and proposals from licensed Construction Managers in good standing to perform construction manager services in accordance with Idaho Code § 54-4501 et seq., as determined by MOI.
Written proposals will be received at the offices of Museum of Idaho, 200 N Eastern Ave, Idaho Falls, ID 83402 until 3:00 p.m. local time May 12, 2017. Proposals will be evaluated on the basis of qualifications as specified in this RFQ. A selection committee will evaluate each of the proposals and the committee may choose to conduct interviews with one or more of the firms. The MOI Board will make the final decision regarding the firm chosen for CM/GC services for these projects.
MOI reserves the right to reject any and all proposals, to waive any irregularities in the proposals received, and to accept the proposal that is in the best interest of MOI and the public. The issuance of the RFQ and the receipt and evaluation of sealed proposals does not obligate MOI to award a contract. MOI will pay no costs incurred by Proposers in responding to this RFQ. MOI may in its discretion cancel this process at any time prior to execution of a contract without liability.
A Pre-Proposal Meeting will be held at the MOI offices at 1:30 p.m. on April 28, 2017. MOI strongly recommends attendance by the Proposers.
MOI appreciates your interest in meeting the needs of the Museum of Idaho.
RFQ: CM/GC Services Museum of Idaho Expansion
1.1 Proposal Information
The submission package or envelope must be sealed and plainly marked for delivery as follows:
Please indicate “CM/GC: [name of project] – SEALED PROPOSAL ENCLOSED” on the outside of the envelope.
Proposals shall be submitted as follows:
Museum of Idaho
Attention: Karen Baker
200 N Eastern Ave
Idaho Falls, ID 83402
Sign your proposal. UNSIGNED PROPOSALS WILL NOT BE ACCEPTED. Submittal packages must include ONE (1) signed/printed original proposal and at least Six (6) printed copies of the proposal and ONE (1) flash drive with a digital (PDF) version of the entire proposal. Late or incomplete submissions will not be accepted. Email or fax submissions will not be accepted. DO NOT FAX YOUR PROPOSAL.
Proposal deadline is 3:00 p.m. local time, May 12, 2017
At the time of the deadline above, only the names of the proposers will be made public. Proposer assumes full responsibility for the timely delivery of its proposal package to MOI. Proposer will be responsible for all costs (including site visits where needed) incurred in preparing or responding to this RFQ. All materials and documents submitted in response to this RFQ become the property of MOI and will not be returned.
1.2 Contact with MOI Personnel
All communications by Proposer should be made via the below-named contact. No other direct oral communication (excluding the pre-proposal meeting) with MOI personnel shall occur until the interviews. Address all communications in writing or email concerning this RFQ to:
Museum of Idaho
Attention: Karen Baker
200 N Eastern Ave
Idaho Falls, ID 83402
2.1 Information and Background
The Museum of Idaho, previously known as the Bonneville County Historical Society is a free-standing, non-profit organization dedicated to bringing internationally & nationally-acclaimed
RFQ: CM/GC Services Museum of Idaho Expansion
exhibits to southeast Idaho, preserving and showcasing natural and cultural history, and providing unique educational opportunities for everyone.
The Museum, started from humble beginnings in the old city library building built in 1916, has undergone several renovations and one major expansion which was completed in 2003. The architecture spans 100 years and exterior and interior finishes are reflective of the eras in which they were constructed. The original library building is considered a historical building and the exterior may not be altered without permission.
Currently the Museum has 5,114 ft2 of permanent exhibit space and offers approximately 7,500 ft2 space for various themed exhibits that create unique, cultural opportunities for regional residents and visitors to the area. Education, a focus for the museum, is provided by youth summer camps, the children’s discovery center, and various classes held in the education center.
An increase in visitors, education requests, and exhibit opportunities is requiring the museum to expand its offerings. During 2016 we expect nearly 100,000 visitors will have toured the exhibits and participated in our education programs.
This work will require experience and expertise in staging construction over an extended period of time while accommodating occupied building.
The expansion design for the museum should include, at a minimum, the following:
 A basement with elevator access of approximately 9,000 ft2.
 An approximate 3000 ft2. Climate controlled collections storage space in basement.
 3000 ft2 crate storage area (does not need to be climate controlled.)
 An exhibit space of 10,000 to 12,000 ft2 with 35ft. ceiling and atrium space. “D” room may be considered for conversion to exhibit space.
 Exhibit space structure shall be of sufficient strength and adaptable design to support (hang) large, heavy displays, e.g. WW II era airplane.
 New exhibit area(s) shall have access control from the existing museum space.
 Exhibit space shall have a method to separate display areas (moveable walls) and control acoustics (sound damping).
 A museum quality fully adjustable and dimmable lighting display grid, accessible by a cat walk or dimmers and control board.
 Flexible, museum quality sound system
 Exhibit space shall be temperature and humidity controlled; 70° F(+/-2°) and 50% RH (+/-5%).
 A method to control the amount of exterior light shall be provided for the exhibit space.
 An adjustable 110 V AC power system shall be provided in the floor and overhead exhibit spaces. A 220 V AC and 3 phase power receptacles shall be available in each exhibit area.
 Each floor of the exhibit space shall provide for modular, museum quality projection of HD media.
 A water drain in each exhibit space (at least one on each level) with an accessible hose bib per level.
RFQ: CM/GC Services Museum of Idaho Expansion
 A commercially sized (tractor and trailer) loading dock:
 Able to unload and load a 52 ft. trailer.
 Prefer to have floor of trailer at same level as ground floor of museum.
 An elevator, or lift, to all floors, with enough capacity and size to move large displays. Elevator size 12X10X10 minimum
 Require a 500- 750 sq. ft. climate controlled, secure, access limited collections staging/prep area, adjacent to the loading dock with double doors large enough to accommodate large displays and crates (on a forklift) with adjustable display type lighting.
 Require a 1000 sq. ft. main floor display staging and shop area (for builds) 1000 sq. ft. Cannot be adjacent to collections staging/prep area.
 Require an access controlled educational space, adjacent to the exhibit space(s) with of sufficient size to seat 200, or stand up space for 300 to 500 people, and;
 Controlled, direct outside access.
 PA, projection, and WIFI capable.
 Storage and counter space/cabinets with a commercial sized sink and fixtures.
 Modular, sound controlled and adjustable wall system.
 Readily accessible 150 to 300 sq. ft. storage space.
 Near restrooms. (So can send children without having to accompany)
 A method to control the amount of exterior light shall be provided for the educational space.
General design requirements/information includes:
 Museum security system.
 WIFI capability throughout expansion and existing museum.
 Cat 6A or greater cabling throughout museum expansion area.
 Restrooms require floor drains and shall be constructed of easy to maintain and clean materials (current ones are inadequate). At least one gender neutral bathroom shall be available and must be accessible from current museum area.
 Require a small private “parent area” – changing table, lockable door, and small refrigerator and chair (for nursing mothers) – preferred in current museum, but okay if in expansion area.
 Space above current area may be available for offices – need to complete stairs
 Preference is to not move children’s room (although it may be possible in future)
 Understanding is that the foundation of the Masonic temple part of existing space is sufficient to support a third floor (will need verification)
 The building is partially funded by a grant from the National Endowment for the Humanities. As such, government grant requirements apply, for example Davis-Bacon wage rates.
The final MOI expansion must be designed and constructed to be cost effective and functionally efficient, integrating with the current museum, including aesthetic aspects. The addition may be two or three stories with a target cost to construct at $150.00/sq.ft. Renovation and/or
RFQ: CM/GC Services Museum of Idaho Expansion
restructuring of current interior spaces, if any, should be included in the plans.
RFQ: CM/GC Services Museum of Idaho Expansion
2.2 CM/GC Scope of Services
All CM/GC contracted services must be performed by staff properly licensed in the State of Idaho. The following services are anticipated in the CM/GC Services agreement with MOI. The descriptions are illustrative in nature and not exhaustive. The actual scope of services will be negotiated after this RFQ selection process has been conducted.
Preconstruction Phase, for Design and Bidding and Long Lead Procurement Services:
 Work with MOI staff and the design team to review the project and visit the work areas to become familiar with the project;
 Review draft design drawings and specifications to identify clarity and constructability issues; provide cost estimates as needed;
 Work with staff to develop a project schedule and refine the logistics plans;
 Develop and obtain trade contract scopes and other contract documents;
 Obtain competitive bids for all the work, materials, and equipment; conduct pre-bid meetings and site tours;
 Work with MOI staff and the design team to address questions, issue addendums, and publically open bids;
 Procure long-lead material items.
 Work with MOI staff and design team to value engineer the design and reconcile budget overruns as needed;
 Research and coordinate with specialty contractors and vendors on specialized items.
 Work with MOI staff to derive and negotiate project Guaranteed Maximum Price.
Prior to release of the first package for the subcontractor bidding, CM/GC firm shall submit a bid package estimate that itemizes all bid packages to be bid and awarded and which includes the CM/GC firm’s estimate of the cost of each bid package. As permitted by the Owner, the bid package estimate will include line items for any work the CM/GC firm proposes to self-perform. CM/GC firm’s overhead, profit, and contingencies shall be identified in separate line items. The total of the bid package estimate shall equal the Construction Cost on the CM/GC firm’s most recent estimate.
Construction Phase Services:
 Obtain project bonding, issue subcontracts and trade contracts, and obtain permits for all the work;
 Serve as the General Contractor and as a licensed Construction Manager, including:
o Manage the construction process including the coordination, planning, trade contractor management, manage submittals, and requests for information;
o Review and negotiate change orders, coordinate safety programs, resolve issues and claims;
o Conduct and coordinate inspections, review and pay trade invoices, update construction schedules;
o Conduct coordination meetings;
o Maintain records, record documents and manuals, develop and monitor punch list, coordinate and assist with warranty corrections;
o Coordinate with the MOI administration, user groups, and design team; and
o Plan and provide general condition services such as superintendence, mobilization, storage areas, staging, et cetera
RFQ: CM/GC Services Museum of Idaho Expansion
o Obtain permission and coordinate access with public and private property owners implicated by the construction activity.
2.3 Special Instructions
Throughout the project, the CM/GC firm shall provide MOI with professional construction management and contractor services and represent MOI’s interests in completing the project on time, within set budgets, and as planned with minimum difficulties. It is anticipated that standard AIA or Consensus Docs contracts will form the basis of agreement for CM/GC services to be entered into for the project; provided however, MOI reserves the right to change, modify, or amend the final contract to be entered into by MOI.
3.1 Intent of RFQ
It is the intent of MOI to run a Qualification Based Selection process to select a firm capable of providing the CM/GC services outlined within this proposal. The CM/GC firm ranked highest will be approached to negotiate the contract(s) necessary for these projects. If contracts cannot be negotiated, MOI will then approach the next highest ranked firm to negotiate the contracts.
3.2 Reserved Rights
MOI reserves the right to waive any formalities or defects as to form, procedure, or content with respect to its Request for Qualifications and any irregularities in the proposals received, to request additional data and information from any and all Proposers, to reject any submissions based on real or apparent conflict of interest, to reject any submissions containing in accurate or misleading information, and to accept the proposal or proposals that are in the best interest of MOI. The issuance of this RFQ and the receipt and evaluation of proposals does not obligate MOI to select a firm nor award a contract. MOI may in its discretion cancel, postpone, or amend this RFQ at any time without liability.
3.3 Public Records
If any Proposer claims any part of a proposal is proprietary and cannot be disclosed by the MOI, the Proposer must: 1.) Indicate by marking the pertinent document “CONFIDENTIAL”; and 2.) Include the specific basis for the position that it be treated as exempt from disclosure. Marking the entire proposal as “Confidential” and will not be honored.
MOI, to the extent allowed by law and in accordance with these Instructions, will honor a non-disclosure designation. However, the MOI shall not be liable for disclosure of information that is in the public domain through no fault of MOI, by judicial requirements to disclose, or for disclosure more than 3 years beyond the submittal date. By claiming material to be exempt from disclosure under Idaho Law, Proposer expressly agrees to defend, indemnify, and hold MOI harmless from any claim or suit a rising from MOI’s refusal to disclose such materials pursuant to the Proposer’s designation.
RFQ: CM/GC Services Museum of Idaho Expansion
3.4 Insurance
Prior to executing any contract for CM/GC services with MOI or commencing any work under the contract, the CM/GC firm will be required to provide evidence of the coverages listed below and pay all costs associated with the insurance coverage. Insurance policies or certificates of insurance will name MOI as a named insured, (except professional liability and worker’s compensation insurance) and the CM/GC firm will maintain these minimum insurance coverages during the entire term of the contract:
a. Professional Liability Insurance coverage with minimum coverage of One Million Dollars ($1,000,000.00) per occurrence and a minimum aggregate limit of One Million Dollars ($1,000,000.00).
b. Commercial General Liability Insurance coverage with minimum coverage of One Million Dollars ($1,000,000.00) on an occurrence basis (rather than a claims- made basis).
c. Automobile Insurance coverage with minimum coverage of Five Hundred Thousand Dollars ($500,000.00) per occurrence for owned, non-owned, and hired vehicles.
d. Worker’s Compensation Insurance in an amount as required by statute and Employer’s Liability Insurance in an amount not less than Five Hundred Thousand Dollars ($500,000.00) for each occurrence, for all of the firm’s employees to be engaged in work on the project under contract and, in the case any such work is subcontracted, the CM/GC firm will require Subcontractors and trade contractors similarly to provide Worker’s Compensation and Employer’s Liability Insurance for all the Subcontractors and trade contractors to be engaged in such work.
3.5 Bonding
As the General Contractor, the CM/GC must have the capability to bond for 100% of the contract price of the project estimated at the time the contract is negotiated and until such time that all of the entire projects bid, the overall Guaranteed Maximum Price (GMP) for the work is established, and the bond is delivered to MOI. The performance and payment bonds shall be AIA Document A312, 2010, or a standard surety form certified approved to be the same as the AIA A312 form and shall be executed by a surety or sureties reasonably acceptable to MOI and authorized to do business in the State of Idaho.
3.6 Taxes
MOI is exempt from Federal and State taxes and will execute the required exemption certificates for items purchased and used by MOI. Items purchased by MOI and used by a contractor may be subject to Use Tax. All other taxes are the responsibility of the Contractor and are to be included in the Contractor’s pricing.
RFQ: CM/GC Services Museum of Idaho Expansion
3.7 Anti-discrimination
The MOI will not discriminate in the selection process based on ethnicity, gender, disability/handicap, gender identity, or religion.
4.1 Pre-Proposal Meeting
A Pre-Proposal Meeting will be held at the MOI offices at 1:30 p.m. on April 28, 2017. MOI strongly recommends attendance by the Proposers.
4.2 Forms Submitted
Proposers must submit the following completed forms by the proposal deadline:
a. RFQ Submittal Cover Sheet – Attached to this RFQ as Exhibit A
b. RFQ Waiver and Release – Attached to this RFQ as Exhibit B
c. ONE (1) signed/printed original proposal.
d. At least SIX (6) printed copies of the proposal.
e. ONE (1) flash drive with a digital (PDF) version of the entire proposal.
Failure to submit all requested information may render any proposal unresponsive and void.
4.3 Objections to Specifications or Process
Objections to specifications or RFQ procedures must be in writing and received by MOI, Attn: Chair, Board of Trustees, at least three(3) business days before the date and time of the proposal deadline. The objection must state the exact nature of the protest, describing, if applicable, the location of the protest portion or clause in the RFQ documents and explaining why the provision should be struck, added, or altered, and contain suggested corrections. MOI may deny the objection, modify this RFQ, and/or reject all or part of the objection.
4.4 Addenda
In the event it becomes necessary to revise any part of this RFQ, addenda will be issued. Information given to one Proposer will be available to all other Proposers if such information is necessary for purposes of submitting a proposal or if failure to give such information would be prejudicial to uninformed Proposers. It is the Proposer’s responsibility to check for addenda prior to submitting a proposal. Failure to do so may result in the proposal being declared non- responsive. No addenda will be issued less than four (4) business days before the proposal deadline unless the deadline is extended.
RFQ: CM/GC Services Museum of Idaho Expansion
4.5 Modification or Withdrawal of Proposal
A proposal may be modified or withdrawn by the Proposer prior to the submission deadline set forth in this RFQ. After the submission deadline, the submitted proposal shall remain in effect for a minimum of 90 days for evaluation purposes.
4.6 Protest
If any participating Proposer objects to MOI’s notice of selecting a firm for CM/GC services, that Proposer shall respond in writing to the notice from MOI within seven (7) calendar days of the date of transmittal of the notice, stating the express reason or reasons that the decision of MOI’s Board is in error. Upon receipt of such objection, the MOI Board shall review the award and determine whether to affirm, modify or re-bid, setting forth the reason or reasons for its decision. At completion of the review process, MOI may proceed as it deems to be in the public interest.
5.1 Required Submission Materials and Format
The Proposal format described here is meant to allow uniform review and easy access to information by the evaluation committee. Proposals not conforming to the requested format or not in compliance with the specifications will be considered non-responsive.
a. RFQ Submittal Cover Sheet
b. RFQ Waiver and Release
c. ONE (1) signed/printed original proposal.
d. At least SIX (6) printed copies of the proposal.
e. ONE (1) flash drive with a digital (PDF) version of the entire proposal.
Proposers are invited to include information about innovative methods and/or procedures which they can provide to assist in ensuring successful completion of this project. Unique qualities and/or capabilities and cost efficiencies may be identified. For each of the specific areas listed below, Proposers should include a description of qualifications to serve as a CM/GC.
The proposer must provide responsive narrative to each element of information sought. Simply stating “agreed” or “complies” is not acceptable. In order for Proposer to be eligible for an awarded contract, the proposal must be responsive to this RFQ and MOI must be able to determine that the Proposer is responsible and has the resources and capacity to perform the resulting contract satisfactorily.
Submittal package must include the following information in the sequence set forth below.
Eligible Proposers, at a minimum, must meet the following requirements:
 Have adequate financial resources, or the ability to obtain such resources as required during the performance of any resulting contract;
 Be able to comply with the performance schedule(and its modifications) over the next two years (approximately),taking into consideration all existing business commitments;
 Have a satisfactory record of past performance;
 Have necessary personnel and management capable of performing requirements on a
RFQ: CM/GC Services Museum of Idaho Expansion
resulting contract;
 Be qualified and licensed as an established vendor who regularly engages in the type of business necessary to fulfill the contract requirements;
 Be otherwise qualified and eligible to receive an award under applicable laws and regulations.
Unresponsive Proposals:
Proposals not meeting the following requirements will be deemed unresponsive and will not be afforded consideration:
 A submitted proposal will be deemed unresponsive if the Proposer does not specifically offer all services as specified in the RFQ.
 The proposal must acknowledge that all services, terms and conditions specified in this proposal will be included in the price to be set forth in the contract.
 The proposal must state that this RFQ and the proposal submitted by the Proposer in response to this RFQ will be made a material part of any contract executed between MOI and the Proposer.
Submittal package must include the following information in the sequence set forth below.
RFQ Submittal Cover Sheet (Exhibit A)
RFQ Waiver and Release (Exhibit B)
Signed Cover Letter – limit one page
A signed letter briefly stating the Proposer’s understanding of the work to be done, the commitment to perform the work within the time period, and a statement as to why the firm believes it is qualified to perform CM/GC services for the project.
RFQ: CM/GC Services Museum of Idaho Expansion
Detailed Proposal – organized with the following information:
a. Company Profile:
Describe your firm’s history, size, resources, and philosophy of service, volume of current work, and management techniques and methods along with any other information that would be helpful to characterize the firm.
History, Size, Resources -(2)pages.
Philosophy of Service and Volume of Current Work -(1) page
Management Techniques and Methods -(1)page.
b. CM/GC Approach: Describe the firm’s philosophy and approach to providing CM/GC services. Include a description of typical services provided; how the firm manages budgets, subcontracts and trade contracts, materials purchases, and schedules; how the firm coordinates the work; and the approach to dealing with construction problems such as poor work quality, disputes, etc. Provide an organization chart clearly illustrating proposed staffing.
Approach to Project’s “Required Services”-(2)pages.
Teamwork, Communication, Leadership-(1)page.
Principal and Project Manager Resumes-(2)pages.
Consultant Firms Description – (5) pages.
Organization Chart-(1)page.
Roles and Responsibilities of Key Personnel-(2)pages.
c. Project Manager/Point of Contact: Identify the personnel to whom construction management responsibility will be assigned by names, titles, roles, qualifications, years of experience, project experience, and resumes.
d. Budget Control: submit detailed information of how your firm provides and periodically updates construction cost estimates and participates in value engineering during project design, and successfully tracks and reports construction costs, including line item costs for each bid package, fees, permits, reimbursable costs, CM fees, and all other project costs.
e. Scheduling: Outline how your firm will ensure the proposed staff will be available at the proper times to complete this project on schedule. Describe the primary scheduling techniques the firm uses and the software you will employ to produce an effective construction schedule. Provide examples of successful construction management and scheduling services provided on complex, multi-phase projects. Discuss in detail how you intend to enforce contract schedule compliance.
f. Home Office Support: Describe your home office support staff by name and position and provide a flow chart of how pay requests will be received, approved, and prepared for payment.
g. Previous Similar Experience: List the firm’s experience for the five (5) most similar projects (in terms of size, nature and complexity) completed within the last 10 years. Clearly identify the project scope, cost, and the firm’s responsibilities on the project, and identify the year each project was completed. For each project, provide a reference
RFQ: CM/GC Services Museum of Idaho Expansion
contact name, title, and phone number, and role on the project. Please focus on firm experience – do not include individual experience for projects performed while individuals were employed by other firms. As applicable, describe the firm’s systems approach, including a management plan and project management control systems that will be used on this project for MOI.
5.2 Evaluators Ranking
Each selection committee member will rank Proposers response in the areas listed below:
1.0 General Information
2.0 Company Profile
3.0 Approach to Project and Team Organization
4.0 Past Performance
5.0 Specific Information
6.0 Experience and Relationship with City of Idaho Falls
7.0 Evaluator’s Discretionary Ranking
5.3 Qualification Based Selection
Final selection is made by the MOI Board. The MOI Board has the right to waive or alter submission requirements or to reject any or all submissions, consistent with Idaho law. It is the Proposer’s responsibility to conform to all applicable federal, state and local statutes or other applicable legal requirements. The information provided herein is intended to assist Proposers in meeting applicable requirements but is not exhaustive, and MOI will not be responsible for any failure by any Proposer to meet applicable requirements.
Direct questions to:
Karen Baker
Museum of Idaho
200 N. Eastern Avenue
Idaho Falls, ID 83402
Tel: (208) 522-1400 X3008
A: RFQ Submittal Cover Sheet
B: RFQWaiver and Release
TO: Museum of Idaho
Karen Baker
200 N. Eastern Avenue
Idaho Falls, ID 83402
Tel: (208) 522-1400 x 3008
Firm Name:
Mailing Address:
Physical Address:
Telephone: Fax:
E-mail Address:
Firm’s officer responsible to MOI for CM/GC services contemplated by this RFQ:
Print Name / Title:
Mailing Address:
Physical Address:
Telephone: Fax:
E-mail Address:
License Information: Idaho Public Works Contractor License #
Idaho Public Works Construction Management License #
held by
(name of licensed CM who will be responsible).
The undersigned has read this waiver and release and fully accepts the Museum of Idaho (MOI) discretion and non-liability as stipulated herein, and expressly for, but not limited to, MOI’s decision to proceed with a qualification-based selection process in response to the Request for Qualifications (RFQ) to select a firm to supply CM/GC services to MOI for the project.
A. Discretion of MOI: The firm or individual submitting a response to this CM/GC RFQ agrees that MOI has the right to, unless contrary to applicable state law:
1) Modify or suspend any and all aspects of the process seeking proposals and making any decisions concerning the CM/GC services RFQ.
2) Obtain further information from any person, entity, or group regarding the Proposer, and to ascertain the depth of Proposer’s capability and experience for supplying CM/GC services and in any and all other respects to meet with and
consult with any Proposer or any other person, entity, or group;
3) Waive any formalities or defects as to form, procedure, or content with respect to
MOI’s RFQ to select a CM/GC firm and any response by any Proposer thereto;
4) Accept or reject any sealed proposal received in response to the RFQ, including any sealed proposal submitted by the undersigned; or select any one proposal
over another in accordance with the selection criteria;
5) Accept or reject all or any part of any materials or statements, including, but not limited to, the nature and type of proposal.
B. Non-Liability of MOI:
1) The undersigned agrees that MOI shall have no liability whatsoever of any kind or character, directly or indirectly, by reason of all or any decision made at the discretion of MOI as identified above.
2) The undersigned, including all team members, have carefully and thoroughly reviewed the RFQ and has found it to be complete and free from ambiguities and
sufficient for their intended purpose.
Respondent’s Signature:
Print Name:
Print Title:
Name of Firm: