MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01CA93A2.F856BEE0" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01CA93A2.F856BEE0 Content-Location: file:///C:/E329E2C5/TranferMembershipJan2010use.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" APPLICATION FOR MEMBERSHIP TO LAKE TANGLEWOOD, INC

 

 

 

 

Seller: ______________    Address:______________= ______

 

APPLICATION FOR MEMBERSHIP TO LAKE TANGLEWOOD, INC. INSTRUCTIONS

 

 

 

 =

= ______ TRANSFER OF MEMBERSHIP FORM SIGNED BY CURRENT     MEMBER AND NOTAR= IZED.

 

______ APPLICATION FOR NEW MEMBERSHIP COMPLETED AND NOTARIZED.

 

 ______ CHECK ATTACHED FOR $2500.00 for regular transfers, $1500= .00 for lots with nothing on them, MADE OUT TO LAKE TANGLEWOOD, INC.

 

______ ADDITIONAL CHECK ATTACHED FOR REFUNDABLE DEPOSIT    ($500.00) IF LEASING MEMBERSHIP

 

______ COPY OF THE LEASE BETWEEN THE OWNER OF = THE PROPERTY AND LESSEE IF LEASING MEMBERSHIP

 

 ______ ORIENTATION MEETING COMPLETE= D  (DONE AT CORPORATION OFFICE)

 

______ C= URRENT SURVEY (within two years) ATTACHED TO PAPERWORK (NO APPROVAL WITHOUT)

 

______ CURRENT SEPTIC INSP= ECTION ATTACHED (within one year)

 

______ C= URRENT BOATHOUSES AND SWIM DOCK INSPECTION.  ALL INSPECTIONS ON BOATHOUSES AND S= WIM DOCKS WILL COST $100.00 EACH, PAYABLE TO THE VILLAGE OF LAKE TANGLEWOOD.=

 

______ A= LL OF THE ABOVE COMPLETED AND TURNED INTO CORPORATION OFFICE BY FIVE WORKING DAYS, PRIOR TO REGULARLY SCHEDULED BOARD MEETING.  (The Board meets the Second Monday= and the fourth Tuesday of each month at 6:00pm).

 

NOTE:  NO PAPERWORK WILL BE PRESENTED TO BOARD OF DIRECTORS UNTIL ALL ITEMS ARE COMPL= ETE.  NO EXCEPTIONS!

 

 

 

 

 

 

 

 

 

PROCEDURE FOR SELLING LAKE TANGLEWOOD PROPERTY

 =

Lake Tanglewood is a private club.  When prope= rty is purchased, the buyer must submit an application for membership to be presen= ted to the Board of Directors for approval.&nb= sp; The Board meets the second and fourth Tuesday of each month.  The completed applications must be= in the Corporation Office five working days prior to regular scheduled meeting dates.  Applications w= ill be considered at Board meetings only.

 

REALTORS SELLING PROPE= RTY AT LAKE TANGLEWOOD SHOULD SUBMIT THE MEMBERSHIP APPLICATION IN AMPLE TIME TO PREVENT ANY DELAY= S IN CLOSING SALES.

 

Absolutely no closing of property sales are to be completed prior to Lake Tanglewood Corp. Board approval of membership transfer.

 

FAILURE TO FOLLOW THESE GUIDELINES MAY RESULT IN DELAYED  MEMBERSHIP TRANSFER AND/OR ADDITIO= NAL PENALTIES

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X_____________________________________ Realtor           Date:_______

 

X_____________________________________ Seller      &= nbsp;       Date:_______

 

X_____________________________________ Buyer              Date:______= _

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 IMPORTANT INFORMATION FOR PROSPECTI= VE PURCHASERS OF PROPERTY IN LAKE TANGLEWOOD

 

Lake= Tanglewood is a regulated and controlled Private Club.  All the rules and regulations have= been passed by the duly elected representatives of the club, the Village Council, and the Board of Directors, and are designed to secure and promote the safe= ty, security, tranquility, and welfare of the members.

 

The members under a standard sublease hold some titles to properties and memberships in Lake Tanglewood Club.  Individual members with a general warranty deed hold other titles and memberships in Lake Tanglewood Club.  The Prime Lease to some properties are held by Lake Tanglewood, Inc. whose sole shareholder is Lake Shores Incorporated of Texas (LSIOT), referr= ed to generally as the “Corporation”, as lessee, which lease has b= een extended to September 2157.  E= very sublease to each property contains standard obligations, duties, and rules = to which each member must strictly adhere.

 

“Applicant acknowledges receipt of, and has read a copy of, the Rules and Regulations = of the Lake Tanglewood Club, and in consideration of admittance to membership agrees to be bound by such Rules and Regulations and those hereafter adopte= d as constituting the terms of the agreement between the applicant and the Lake Tanglewood Club.”

 

The function of the Corporation includes the following:

 

1.      Regulate compliance by the membership with the= terms of the Prime Lease and subleases of Lake Tanglewood property= .

 

2.      Oversee and provide basic services including, = but not limited to, roads, water services, and controlled access to the Village= and recreational facilities of the Lake Tanglewood Club.

 

3.      Administer and regulate corporate properties o= f Lake Tanglewood Club.

 

4.      Set and collect dues and/or assessments, fees,= and water charges as necessary to maintain the objectives and purposes of the L= ake Tanglewood Club.

 

5.      Approve all transfers of memberships and subleases to new purchasers.

 

 

 

 

 

 

X________________________    Date:__________=   &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;      

  Initial    buyer(s) =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             

 

 

 

 

 

 

NO SUBLEASE AND/OR MEMBERSHIP MAY BE TRANSFERRED TO A PROSPECTIVE PURCHASER OR LESSEE WITHOUT THE APPROVAL OF THE BOARD OF DIRECTORS OF THE CORPORATION (LSIOT, INC.).  THE BOARD ACTI= ON TO TRANSFER WILL BE TAKEN AS SET FORTH IN “STANDARD PROCEDURE TO TRANSFER A SUBLEASE AND MEMBERSHIP”.  IT IS THE DUTY AND OBLIGATION OF E= ACH SELLER AND PURCHASER OR LESSOR AND LESSEE TO BE AWARE OF AND TO COMPLY WITH= THE TRANSFER REQUIRMENTS BEFORE INCURRING EXPENSES IN ANY REAL ESTATE CONTRACT = OF SALE OR LEASE IN = THE EVENT THAT THE TRANSFER IS NOT APPROVED BY THE BOARD OF DIRECTORS.  MEMBERSHIPS ARE LIMITED TO INDIVIU= ALS; THERE CAN BE NO DUAL OR MULTIPLE PARTY OWNERSIP OF A MEMBERSHIP, OR CORPORATE MEMBERSHIP OTHER THAN AS STATED IN BOARD POLICY #7.  ALL PROSPECTIVE MEMBERS MUST AT= TEND AN ORIENTATION ON THE RULES AND REGULATIONS OF THE L= AKE TANGLEWOOD CLUB. 

 

 

The Village of Lake Tanglewood is an incorporated Village under the laws of the State of Texas.  It is similar to a city and is gov= erned by a Mayor and five Village Alderman.  In some cases the Village has co-extensive and overlapping jurisdict= ion with the Corporation.  The ele= cted officials of the Village (the Village Council) has requirements for conduct= and other activities within the Village limits and is primarily responsible for exercising jurisdiction in “law and order” and “zoning and building requirements”.

 

The following is a summary of some of the rules and regulations established by = the Corporation and/or by the Village of Lake Tanglewood, which should be considered by all prospective purchasers of property in Lake Tanglewood:

 

1.      All vehicles, motorcycles, boats, golf carts a= nd ATV’s belonging to a member and used within the lake area must be ide= ntified with a Lake Tanglewood vehicle, cycle or boat registration sticker.

 

2.      Recreational Activities:  All recreational activities includ= ing, but no limited to, the use of the lake area, the golf course, and other are= as of the lake are limited to use by a member, or his or her family under the = age of 21 living with the member.  All guests of a member must be accompanied by the member to use these facilities.

 

3.      Guests:  In addition to the above, all members must inform the gate guard to authorize admittance for their guests.&nbs= p; All members are personally responsible for any action or damage done= by such guest(s) and can be called upon monetarily for such actions or damages= .

 

X__________________________ Date:___________

  &= nbsp; Initial  buyer(s)

 

 

 

 

 

 

 

 

 

4.      Any new construction or modification of existi= ng structures which changes the outside walls or roof line must have a Building Permit issued by the Village, subject to approval by the Corporation, prior= to the start of any work.  A perm= it for excavation, leveling, grading or filling must be obtained from the Corporat= ion prior to doing the work.  Some= of the Village and/or Corporation requirements are listed below.  This listing is for basic informat= ion ONLY and does NOT constitute all the existing requirements or regulat= ions:

 

<= span style=3D'font-weight:normal'>a.      = Set-back from side- lot lines shall be 10% of = the total width of the structure, but in no case less than 5’ from each s= ide.

<= span style=3D'font-weight:normal'>b.      No house shall be constructed containing less = than 1,750 square feet, exclusive of open porches, garages, or carports, and sha= ll exceed $60,000.00 in construction costs.

<= span style=3D'font-weight:normal'>c.      = All structures shall be completed within one y= ear of the date of the approved building permit.

<= span style=3D'font-weight:normal'>d.      All septic tanks and drain fields shall be ins= talled (or re-installed when necessary) to comply with TNRCC and be inspected and approved by the Bi-City County Health Department.

<= span style=3D'font-weight:normal'>e.      = No water wells are permitted, and each purchas= er must connect to the existing overall Corporation water system.

<= span style=3D'font-weight:normal'>f.      =   All boat = houses and docks have certain size, placement, and construction restrictions and a= lso require a building permit prior to construction.

<= span style=3D'font-weight:normal'>g.      = In addition to the general requirements, ordin= ances, and rules of the Village of Lake Tanglewood, each membership contains the following provision:  “No improvements of any kind may be built or erected on the property until and unless the plans and specifications for said improvements and the location = of said improvements on the property have first been presented to and approved= by the Village subject to the approval of the Corporation.”

<= span style=3D'font-weight:normal'>h.      = In addition to the above, it should be pointed= out to prospective purchasers that some of the vacant lots in Lake Tanglewood do not have previsions for water service and/or road service. Before signin= g a contract to buy, prospective purchasers should check the lot locations; otherwise the purchasers may be required at their own expense, to furnish a= nd maintain roadways, utilities, and water service to certain lots.=

<= span style=3D'font-weight:normal'>i.      =    All prosp= ective purchasers should check the location of the lot being purchased to determine its “flood plane” status and whether it is susceptible to rising water levels.

 

 

 

X____________________________ Date: __________= _

  &= nbsp; Initial buyer(s)

 

 

 

 

 

 

 

 

5.      The Village of Lake Tanglewood has the power to enforce the following regulations and ordinances:

 

<= span style=3D'font-weight:normal'>a.      = The conduct of members and guests in relation = to offenses involving disorderly conduct, moral turpitude, public drunkenness, public nuisances, and violations of any other laws and ordinances of the Village of Lake Tanglewood, Randall County, or the State of Texas.  The Corporation has the rights to = assess penalties as described in the rules and regulations handbook for violation = of the rules.

<= span style=3D'font-weight:normal'>b.      Pets must be kept under control of the owner.<= span style=3D'mso-spacerun:yes'>  Pets are required to wear a collar= with current vaccination tags and a tag with owners name and address.  Running at large is unlawful as we= ll as biting, packing, and excessive barking.  

 

6.      Patrolmen are provided by Lake Tanglewood for basic safety such as enforcing speed limits.  They are also provided to enforce = rules on the water, such as no-wake zones.  All watercraft must have current Lake Tanglewood stickers.  Members driving the watercraft must have completed the appropriate safety course.  The lake remains a use a= t your own risk property.=

 

The foregoing information is furnished to you as a prospective purchaser in Lake Tanglewood.  It is designed only to be highligh= ts and a summary of some of the important details to be considered by you before y= ou commit to purchase property in our community.  There are many more rules a= nd regulations of which you should become informed if you decide to buy property.  These rules and regulations may change from time-to-time for the benefit of our community.

 

As stated, we are a regulated and controlled community, and we hope that you, = as a potential buyer, will find this a benefit to property ownership in Lake Tanglewood.

 

 

 

 

 

X__________________________________       X____________________________

     Buye= rSignature        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          BuyerSignat= ure

 

 

Date:____________        &= nbsp;           &nbs= p;            &= nbsp;     Date:____________  

 

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STANDARD PROCEDURE FOR THE TRANSFER AND/OR A SUBLEASE OF MEMBERSHIP

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1.&n= bsp;     All compl= eted components of the Standard Application Form with the transfer fee, must be presented at the Corporation Office no less than (5) five working days prio= r to a regular meeting of the Board. Regularly scheduled LT Corp. Board meetings= are the second and fourth Tuesday evening of each month.

 

2.&n= bsp;     The Board= will make every effort to process the application at the first regular scheduled meeting after the application is received with all requirements being met; = but if for any reason the Board feels that additional time is needed, the decis= ion may be postponed until the next regular meeting, at which time the decision= to approve or deny will be made.

 

3.&n= bsp;     If the application is denied, any fees or deposits held by the Corporation will be returned to the proper party.

 

4.      Approval by the LT Corp. Board of an applicati= on to transfer, and payment of the transfer fee, does not entitle the purchaser or lessee to Lake Tangl= ewood Club privileges.  The <= u>transfer is not effective until a signed copy= of the warranty deed is presented to the Corp. office showing that the names on the deed are exactly as those names provided on the Lake Tanglewood members= hip application and the prospe= ctive member has completed orientation and the most current survey (within two years, provided no structural changes or additions have been made within the two year period) is received= at the Corporation Office.  At th= at time, the new member may apply for issuance of I.D. cards and vehicle stick= ers and may begin enjoying the privileges of Lake Tanglewood Club memberships.<= o:p>

 

5. Board approval of an Application to Transfe= r will expire if not consummated within sixty (60) days of Board approval.  If the transfer is not completed w= ithin sixty days, approval is withdrawn, and any fees or deposits held by the Corporation will be returned to the proper party.  The application may be resubmitted= at a later date.

 

 

 

 

 

X_______________= ____ Date: ____________

   Ini= tial buyer(s)
LAKE = SHORES INCORPORATED OF TEXAS (LSIOT)

LAKE TANGLEWOOD, TEXAS

 

STANDARD APPLICATION FORM FOR TRANSFER OF PROP= ERTY AND MEMBERSHIP AS APPROVED BY THE BOARD OF DIRECTORS OF LSIOT, INC.<= /u>

 

 

TO:  The Board of Directors<= /span>

         LSIOT, Inc.    &= nbsp;  

 

 

PRESENT MEMBER

 

I, _______________________________________________ the present owner of member= ship on the following property:

 

Address: _____________________________________

 

        =             &nb= sp;    House __________ Lot ___________ = I.D.# __________

 

Legal Description: ________________________________________________________<= /o:p>

 

do apply for a transfer of the above property and membership by (sale) or (lea= se) to the following applicant.  I certify that all dues, water, and fees, and any other charges owed w= ill be paid in full at the time of transfer.  The transfer fee will be paid, and= all vehicle, boat, or cycle registration stickers issued by the Corporation wil= l be removed and returned to the Corporation prior to transfer.  By the signature affixed to this document this date, it is agreed that there will be no further access to or utilization of the facilities of the Lake Tanglewood Club.

 

______________________

Signature of Present Member

 

Executed this __________ day of ______________________, 20___.

 

THE STATE OF _________________

 

THE COUNTY OF ________________

 

This instrument was acknowledged before me on the ___ day of ______________, 20_= __

By _______________________

 

NOTARY PUBLIC ________________________

COUNTY, STATE OF _____________________

MY COMMISION EXPIRES ________________


PROPOSED MEMBER/APPLICANT

 

 

 

 

 

I ____________________________________ do hereby apply for the transfer of the here in above described property and membership in LSIOT.  I do submit and certify to the fol= lowing information.

 

NAME IF FULL _________________________________________________________=

 

AGE _______        =             &nb= sp;   MARITAL STATUS __ SINGLE  __ MARRIED

 

SSN _______________________

 

<= span style=3D'font-weight:normal'>DRIVERS LICENSE STATE AND # _________________

 

SPOUSES NAME IN = FULL ________________________________________________

 

SPOUSES: SSN _______________________ DRIVERS LICENSE # _______________=

 

CHILDREN:

 

NAME        =             &nb= sp;            =             &nb= sp;         AGE        RESIDENCE

 

________________= _______________     ____        ______________________________

 

________________= _______________     ____        ______________________________

 

________________= _______________     ____        ______________________________

 

________________= _______________     ____        ______________________________

 

________________= _______________     ____        ______________________________

 

RESIDENCE ADDRES= S FOR LAST FIVE YEARS:

 

ADDRESS ________________________________ FROM __________ TO _________

 

ADDRESS ________________________________ FROM __________ TO _________

 

ADDRESS ________= ________________________ FROM __________ TO _________

 

ADDRESS ________________________________ FROM __________ TO _________

 

ADDRESS ________________________________ FROM __________ TO _________

 

 

 

 

PLACE OF EMPLOYM= ENT _________________________________________

 

POSITION _______________________ LENGTH OF EMPLOYMENT ______ Yrs.<= /p>

 

BUSINESS ADDRESS__________________________

 

<= span style=3D'font-weight:normal'>CITY _______________ STATE ____ ZIP __________ PHONE # (       ) __________

 

NAME OF <= u>THREE BUSINESS REFERENCES:

 

NAME ___________= __________ ADDRESS _________________________________

 

NAME _____________________ ADDRESS _________________________________<= /span>

 

NAME _____________________ ADDRESS _________________________________<= /span>

 

I do hereby cert= ify to the following:

 

1.&n= bsp;     I am of g= ood moral character and have not been convicted of any felonies or offenses involving moral turpitude or disorderly conduct.

2.&n= bsp;     I will be responsible for any misconduct or damages caused by members of my family an= d/or my guests in the Lake Tanglewood area.

3.&n= bsp;     I acknowl= edge receipt of, and have read a copy of the Rules and Regulations of the Lake Tanglewood Club, and in consideration of admittance to those hereafter adop= ted as constituting the terms of the agreement between the applicant and the La= ke Tanglewood Club.

4.&n= bsp;     If approv= ed for membership, I will inform myself of all Rules and Regulations of LSI= OT and of the Village of Lake Tanglewood and will abide by the same.

5.&n= bsp;     By execut= ion of this instrument, I do authorize the Board of Directors of LSIOT to obtain l= aw enforcement records and credit bureau records for application purposes.

6.&n= bsp;     I underst= and that it is the policy of the Corporation to encourage a peaceful resolution= of disputes with its Members through alternative dispute resolution procedures.  I agree to submit= to mediation any dispute with the Corporation or another Member concern= ing any activity at Lake Tanglewood that can= not be resolved in good faith through informal discussion.

 

Signature: _______________________________________________

 

Executed this __________ day of ______________________, 20___

 

THE STATE OF _________________

 

THE COUNTY OF ________________

 

This instrument was acknowledged before me on the ___ day of __________, 20___

By _______________________

 

NOTARY PUBLIC ________________________

COUNTY, STATE OF _____________________

MY COMMISION EXPIRES ________________

 

 

 

SPECIAL LEASING INSTRUCTIONS FOR PROSPECTIVE APPLICANT LEASING PROPERTY/MEMBERSHIP

 

 

 

 

The Board of Dir= ectors passed a motion on April 12, 1999, as follows:

 

1.&n= bsp;     Any appli= cant leasing property/membership will be required to pay to the Corporation the <= span style=3D'font-weight:normal;mso-bidi-font-weight:bold'>$2500.00 for regular transfers, $1500.00 for lots with nothing on them and an additional $500.00 deposit.  The $500.00 deposit is refundable at the time the lease is completed if all dues and other charges toward the property are current.

 

2.&n= bsp;     The compl= eted Standard Application Form, with the transfer fee and refundable deposit, mu= st be presented to the Corporation Office not less than five (5) working days prior to a regular meeting of the Board.

 

3.&n= bsp;     The Board= will make every effort to process the application at the first regular meeting a= fter the application is presented as described in (2) above, but, if the Board f= eels that additional time is needed the decision may be postponed until the next regularly scheduled meeting, at which time the decision to approve or deny = will be made.

 

4.&n= bsp;     If the application is denied, any fees or deposits held by the Corporation will be returned to the proper party.

 

5= .      Approval by the Board of an application to tra= nsfer and payment of the transfer fee does not entitle the purchaser or le= ssee to Club privileges.  The trans= fer is not effective until a duly designated officer of the Corporation signs a= ll appropriate documents and prospective member has completed orientation.  Prior to any sti= ckers and I.D. cards being issued to the new lessee, all stickers and I= .D. cards from the owner of the property must be returned to the Corporation.

 

6.&n= bsp;     A copy of= the lease between the owner of the property and the lessee must accompany the application for the transfer of membership.

 

7.&n= bsp;     Board app= roval of an Application to Transfer will expire if not consummated within sixty (= 60) days of Board approval.  If the transfer is not completed within sixty days, the application is withdrawn, = and any fees or deposits held by the Corporation will be returned to the proper party.  The application may be resubmitted at a later date.

 

 

X_______________= _______________________ Date:_____________

            =             <= /span>Sign= ature of Leasee(s)

 

 

 

 

WATER SYSTEM SERVICE AGREEMENT

 

 

 

 

 

The following ar= e the terms of the service agreement between the Lake Tanglewood, Inc.

 

Public Water Uti= lity (Water System-Maintenance Department) and (Customer).

 

A.&n= bsp;    The Water System will maintain a copy of this agreement as long as the Customer’= ;s premise is connected to the Water System.

 

B.&n= bsp;    Customer = will apply for an Irrigation Permit through the Water System for any irrigation work done to premise.

 

C.&n= bsp;    Customer = will allow his property to be inspected for possible cross-connections and other unacceptable plumbing practices.  Inspections will be conducted by the Water System employees or its designated agent prior to initiating new water service, when there is reaso= n to believe that cross-connections or other unacceptable plumbing practices exi= st, and/or after any major changes to the private plumbing facilities.

 

D.&n= bsp;    The Water System will notify the Customer in writing of any unacceptable conditions t= hat are identified during the initial inspection or the periodic inspection.

 

E.&n= bsp;     Customer = will immediately correct any unacceptable plumbing practices on his/her premises= .

 

F.&n= bsp;     Customer = will, at his expense, properly install, test, and maintain any backflow prevention device required by the Water System.  Copies of all testing and maintenance records will be provided to the Water System.

 

G.&n= bsp;    The Water= System CANNOT GUARANTEE uninterru= pted services.

 

If Customer fails to comply with the= terms of the Water System Service Agreement, the Water System will, at its option, terminate service.

 =

 

 

________________= _________________

CUSTOMER NAME

 

________________= _________________        =             &nb= sp;            =          __________________

CUSTOMER SIGNATU= RE        =             &nb= sp;            =             &nb= sp;            =      DATE


 

 

 

 

 

 

 

SPECIAL = REQUEST FOR VEHICLE STICKER AND IDENTIFICATION CARD

 

I have signed and delivered to the business office = of Lake Tanglewood, Inc., the “Standard Application Form For Transfer of Property and Membership” and the transfer fee.  I have received and read a copy of= the Rules and Regulations of the Lake Tanglewood Club.  I understand that the Rules and Regulations prohibit the joint ownership as tenants-in-common (i.e. ownersh= ip by multiple persons) of a building lot within the recreational area and of a membership in the Lake Tanglewood Club.&nb= sp; I submit this Special Request to the Board of Directors of Lake Tanglewood, Inc., in accordance with the provisions of Article I, Section 7. C., for a Vehicle Membership Sticker and/or Lake Tanglewood, Inc., Identification card for:

 

_________________________________

Name of New Member

 

for the reasons stated below:

______________________________________________________= __________________

 

______________________________________________________= __________________

 

______________________________________________________= __________________

 

 

Signature: ______________________________

 

Address:   ______________________________

 

        =          ______________________________

 

Telephone:  _____________________________

 

 

THE DECISION OF THE BOARD OF DIRECTORS IS AS FOLLOWS:<= /p>

 

Vehicle Sticker        =   (Approved/Denied)

Identification Card    (Approved/Denied)

 

Signature:  ________________________________ Date:  _______________________

 

 

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