Construction safety generally needs to sign a letter of responsibility to clarify the responsibility of the construction unit. The letter of responsibility is a written document stating the responsibility. Especially when a job involves multiple departments, it is necessary to clarify the scope of responsibilities and responsibilities, which are mostly used side by side. The following is the construction safety responsibility book I compiled, hoping to help everyone. Welcome to check.
Responsibility Letter for Building Safety (Selected Text 1)
In order to effectively curb the safety accidents in the field of building construction and strengthen the construction safety management of village (residential) housing construction projects, according to the People's Republic of China (PRC) Construction Law, the People's Republic of China (PRC) Safety Production Law and other relevant laws and regulations, combined with the actual situation of a town, the town government signed a letter of responsibility for construction safety management with the builders of the buildings under its jurisdiction.
A, where my town within the jurisdiction of the collective construction projects and villagers' self-built housing projects, before the project starts, the construction party needs to go through the project start-up filing procedures at the urban construction department of the Town People's Government, and sign the safety management responsibility letter at the Safety Supervision Office of the Town People's Government.
Two, construction projects, should choose qualified units or qualified individuals to design and construction projects, and bear the responsibility for project safety according to law.
3. For the construction team hired by the villagers themselves, the villagers shall sign a safety responsibility letter with the hired construction team to clarify their respective rights, obligations and safety responsibilities, and the villagers shall urge the person in charge of the construction team to do a good job in safety education for employees.
Four. Safety production duties that operators should perform after admission: master safety production skills, participate in safety training, obey safety management, abide by rules and regulations, and correctly wear and use labor protection articles, such as safety helmet, safety belt, goggles, dust mask, insulating gloves, insulating shoes, etc.
Five, the construction site of the construction hole, stairs, elevators and openings, as well as in the balcony, roof and other unprotected limb operations, according to the construction site protection standards, correctly set up protective devices, limb set up two protective railings, closed with federated eye network.
Six, the construction of temporary electricity management
1, temporary power distribution system should adopt three-level distribution, step by step protection. The installation and internal setting of distribution boxes and switch boxes at all levels must comply with the relevant regulations, and the electrical appliances in the box must be reliable and intact, and their selection and setting values should comply with the regulations. Switchgear should be marked with its purpose, and the wiring diagram should be drawn on the front door of the electrical box.
2, the use of line lights and low-voltage lighting lamps, the power supply voltage should not exceed 36 V. When working in damp and metal containers, low-voltage lighting should be used, and the lighting voltage should not exceed 24 V.
3. When using small electric tools, insulating gloves and shoes should be worn, and the cables used should meet the requirements of relevant regulations.
Seven, construction machinery safety management
1. All machinery used shall comply with relevant regulations and requirements, and shall be maintained regularly, and the "cross operation method" of cleaning, lubrication, firmness, adjustment and corrosion prevention shall be strictly implemented.
2, the use of mixers, winches, steel processing machinery and other equipment operators, should hold relevant certificates, and operate in strict accordance with the safety operation procedures.
3. The safety protection devices of mechanical equipment on the construction site must be complete, sensitive and reliable.
4. In the process of operation, temporarily rented cranes, such as car cranes, should ensure a safe working environment and avoid cranes working under transmission lines; Simultaneously at
In the process of lifting materials, there should be someone who is responsible for the command.
Eight, the construction party should conscientiously perform the duties of construction safety management, responsible for safety construction management, such as safety accidents caused by the construction party's failure to perform the construction safety regulations, the town people's government will give necessary sanctions within its scope of authority.
Party A: _ _ _ _ _ _ (signature and seal) Party B: _ _ _ _ _ _ _ (signature and seal)
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Letter of Responsibility for Building Safety (Excerpt 2)
After a peaceful and happy summer vacation, we started our study and life in the new semester with fond memories of summer vacation life, longing for the new school year and yearning for the new semester. This semester, our school still takes student safety as the primary task, and arranges two teachers to follow the car all the time, responsible for the safety of students getting on and off and the management of students in the car. Based on the actual situation of students' travel in our school, the responsibility book for students' travel safety in Mingde Primary School is formulated. I hope that parents will actively cooperate with the school to ensure the safe, healthy and happy growth of their children.
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2. Please ask parents to pick up and drop off on time according to the place and time of the ride. Both parties should take the safety of students as their own responsibility.
If the students arrive at the scene later than the specified time, please ask parents to send the students to school in person.
4. If parents don't need to pick up students at the bus stop due to special circumstances, or parents don't pick up students at the bus stop, please ask parents to consult the bus teacher and class teacher directly.
Parents can't leave the site in the morning until their children get on the bus safely. (Fire Safety Responsibility Letter) Parents leave early, and children have a safety accident while waiting at the site, and the consequences are at their own risk; After school at night, parents must pick up their children at the scene in advance. If parents don't pick up their children on time or at the site, the parents will bear the consequences because the children get off the bus without parental supervision and a safety accident occurs at the site or on the road.
6. Students are not allowed to get on and off in a crowded way. Get up and down in order, and fasten your seat belt after getting on the bus. Take a civilized bus to ensure safety.
7. If the students who take the bus violate the school regulations and don't listen to dissuasion, the school will automatically give up taking the bus and can't take the bus again this semester.
Attachment: Sites in charge of Teacher Che: Teacher: _ _ _ _ _ _ (Bug, Liu Hu, Zheng Wangjia, Fanhu, Brick Factory, Bridge Team 1-3,) Teacher Xiao: (Yaoshan, Liu Hu, Zheng Wangjia, etc.). This responsibility shall come into effect as of the date of signing.
Party A: Mingde Primary School
Signature of Party B (student guardian):
September 20th __ 1
Letter of Responsibility for Building Safety (Excerpt 3)
In order to conscientiously implement the spirit of the relevant documents on strengthening the safety production management of coal mining enterprises at the national, provincial, prefectural and county levels, and further clarify the responsibilities of each post, so as to ensure safe production for 20 years. According to the actual situation of our mine, a 20-year safety target responsibility letter was signed, and the mine manager and the chief engineer signed the following safety target responsibility letter.
First, the goal of safe production (30 points)
1, there was no serious injury or personal injury accident in this mine throughout the year, and the seven-level minor injuries were controlled within 1 person.
2, resolutely put an end to gas, dust, water, fire, roof, mechanical and electrical, transportation and other major accidents, the control index is zero.
3. Under the premise of ensuring safety, complete the production tasks assigned by the company with good quality and quantity.
4, put an end to a loss of more than ten thousand yuan of equipment accident.
Two, the main technical tasks of production safety (70 points)
1, adhere to the policy of "safety first, prevention first, comprehensive management", seriously organize employees to study and train knowledge of coal mine safety technology, laws and regulations, and effectively improve the ideological understanding of coal mine work.
2, earnestly perform the duties of engineers, responsible for mine "one ventilation and three prevention" management, participate in gas emission and control, and supervise and provide technical service guidance.
3, carefully prepare the annual mine disaster treatment plan and mine major accident emergency plan, and assist the mine manager to organize emergency rescue drills and provide first-hand raw materials.
4, responsible for the supplement, modification, preparation of safety technical rules and regulations applicable to this mine and all kinds of safety technical operation procedures, mining operation procedures and safety technical measures, and is responsible for the audit.
5. Make a safety learning and training plan, and regularly train employees on safety technical knowledge.
6, pays special attention to the mine gas monitoring management, to ensure the normal operation of gas monitoring, accurately print out the gas daily report.
7, according to the measured data, draw a good mine excavation engineering plan, underground control diagram, ventilation system diagram, disaster prevention circuit diagram and fill in on schedule, and other kinds of maps timely supplement, modify and improve.
8, to assist the mine manager pays special attention to the mine safety management.
9. If the chief engineer fails to perform his duties during his tenure and causes an accident, he must take full responsibility. If the circumstances are serious, it shall be reported to the judicial organ for legal responsibility.
10, with no less than 12 trips per month.
Third, reward.
1, with zero management of safety accidents in the whole year as the standard, and the completion of various indicators and tasks in the whole year as the standard, the prize is 100%.
2, in the same year, the general minor injury accident does not exceed 80% of the third prize; Reward 60% above level 4 and below level 6.
3. More serious accidents will not be rewarded.
Fourth, punishment.
Those who cause serious consequences due to dereliction of duty and irresponsibility shall be severely punished and punished according to 30% of the total accident losses. If a crime is constituted, criminal responsibility shall be investigated according to law.
Matters not covered in this responsibility book shall be implemented according to "Coal Mine Safety Regulations".
Appraiser: Mabai Town Coal Mine in Maguan County Appraiser: Mabai Town Coal Mine in Maguan County.
Signature of mine manager: signature of chief engineer:
date month year
Letter of Responsibility for Building Safety (Excerpt 4)
Party A:
Party B;
1. Party A's safety responsibility:
1. 1 Review the qualification certificate of enterprise legal representative, enterprise legal person code and tax registration certificate provided by Party B for review and filing.
1.2 Review the safety qualification examination form of the outsourcing engineering construction enterprise filled out by Party B, including the general situation of the construction personnel, the special operators and the copy of the employment certificate, and review the original list certificate of the project director, the construction technical director and the site safety director provided by Party B, which must be confirmed by the competent department. Party A shall issue the construction certificate to Party B in time as required.
1.3 Party A shall review and guide the three measures plan submitted by Party B in advance, and supervise Party B to strictly implement it after it is qualified. When necessary, or according to the requirements of Party B and safety regulations, Party A shall be assigned to supervise.
1.4 Before the commencement of construction, Party A shall be responsible for fully explaining the working conditions and environment of the site to the person in charge of Party B and the person in charge of on-site construction, engineering technicians and construction personnel, and disclosing relevant safety precautions, with complete records or materials.
1.5 During the construction period, Party A has the right to supervise the safety of the construction site. If it is found that illegal operation endangers personal and equipment safety, it can be stopped and corrected in time, and it has the right to stop its work when necessary, and put forward rectification requirements to Party B. ..
2. Party B's safety responsibility
2. 1 you must have three valid certificates issued by the state administrative department: a full set of copies of the business license issued by the administrative department for industry and commerce, a copy of the enterprise construction qualification certificate issued by the construction department, and a copy of the construction safety qualification certificate.
2.2 provide copies of the qualification certificate of the legal representative of the enterprise, the code certificate of the enterprise legal person and the tax registration certificate, and at the same time provide the original economic contract signed by the legal person, the safety responsibility letter and the project contracting license for entering (leaving) the city.
2.3 Before starting work, Party B shall fill in the Safety Qualification Examination Form of Engineering Construction Enterprises and the general situation of construction (operation) personnel, provide the list of operators of special types of work and a copy of their employment certificates, and provide the original list of project leaders, construction technical leaders and site safety leaders confirmed by the competent department.
2.4 Before starting work, organize all on-site construction personnel to make safety technical disclosure, clarify the work tasks, and make the personnel at all levels on the construction site master the engineering characteristics and safety operation procedures, construction safety measures and safety precautions. Regularly carry out safety activities and summaries for construction personnel, and make records, and invite Party A to send personnel to attend if necessary.
2.5 Provide the construction organization plan, construction operation plan, safety management system, organizational measures and technical measures for maintenance projects before commencement, and formulate individual measures for complex or dangerous projects.
2.6 It is forbidden for minors, the elderly, the weak and the disabled to use it. New personnel entering the construction site (including temporary workers, contract workers, laborers) must carry out three-level safety education, hand over to treat on-site safety precautions, and the relevant records and materials are correct and complete before entering the site for operation. It is strictly forbidden to use temporary workers, migrant workers or labor cooperative workers to engage in highly technical work. Temporary migrant workers can only carry out ground auxiliary work after receiving safety education suitable for on-site operation, and Party B shall be responsible for the safety responsibility of migrant workers and temporary workers.
2.7 During the construction period, all kinds of transportation tools, equipment and tools shall be provided by Party B ... The construction machinery, instruments and protective facilities used in the project must have safety inspection records. Party B shall be responsible for the repair and maintenance of vehicles, equipment and tools, as well as the expenses for failures or casualties during use. Party A shall not be jointly and severally liable.
2.8 In the process of construction, Party B shall strictly implement the safety operation rules, take various safety measures, designate special personnel to take charge of safety work, and designate safety personnel. For the construction of equipment in use, a detailed construction plan shall be worked out with Party A before construction. If potential safety hazards are found during the construction, Party B shall immediately stop work, report to Party A and other relevant functional departments, and take measures to rectify and ensure that nothing is lost before resuming work. Construction personnel must wear safety protection articles correctly during operation to ensure personal and equipment safety during construction.
2.9 Party B's construction personnel shall hold the employment certificate issued by the labor department before taking part in the construction. Personnel engaged in vertical transportation machinery, installation and disassembly, blasting and other special operations. You must receive special safety operation training in accordance with the relevant provisions of the state and obtain the qualification certificate for special operations before you can work at your post. All construction personnel (including migrant workers) must hold relevant certificates according to Party A's regulations.
2. 10 party b shall set up obvious safety warning signs at dangerous parts of the construction site. Party B shall take special protective measures for adjacent buildings, structures, underground pipelines, power and communication lines that may cause damage during construction. If the existing facilities are damaged due to unprotected or improper protection, Party B shall bear all the responsibilities.
2. 1 1 Conduct on-the-spot reconnaissance of crossing and high and low voltage lines along the line in a timely and detailed manner, and provide written materials for Party A's coordination and cooperation.
2. 12 party b must accept the supervision and guidance of party a, and report to party a immediately in case of personal accident or endangering construction safety. The person in charge of Party B (the first person in charge of safety construction) must promptly rectify the effective opinions put forward by Party A..
2. 13 Be responsible for Party B's responsibilities as stipulated in the contract.
3. Safety assessment:
3. 1 If Party B's personnel violate this Responsibility Letter or the Safety Regulations and safety rules and regulations, Party B shall bear all safety responsibilities for all the consequences arising therefrom.
3.2 During the contract period, if a major safety accident is caused by Party B's poor maintenance or inadequate safety protection measures, Party B shall bear all consequences. In addition, Party A may cancel its maintenance qualification and terminate the contract.
3.2 If Party B's personnel actively take effective preventive measures, and do not violate this responsibility book or safety regulations and safety rules and regulations, and there is no responsibility safety accident during the contract period, Party A shall give appropriate rewards to Party B's safety work.
4. This responsibility letter is in quadruplicate, with Party A and Party B holding two copies respectively. Matters not covered in the letter of responsibility shall be settled by both parties through consultation. This responsibility shall come into effect after being signed by both parties.
Party A's Seal Representative:
Seal of Party B's Representative:
Responsibility Letter for Building Safety (Part V)
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According to the requirements of the central government, provinces, cities and counties for safety work and the principle of responsibility to people, in order to ensure the safety of students' lives and effectively grasp the needs of students' safety education and management, this responsibility letter was signed through consultation between the class teacher and parents.
First, the class teacher should take various forms to carry out extensive publicity and education on safety knowledge, enhance students' safety awareness and improve their self-protection ability.
Second, the head teacher should do a good job in students' safety and establish a class safety system.
Third, the class teacher should strengthen the safety inspection of classrooms, corridors, playgrounds and other places at ordinary times, report the relevant situation to the school in time, and eliminate potential safety hazards.
Four, when students encounter dangerous situations at school, the class teacher should come forward to protect the students' personal safety.
5. Parents are the main guardians of students and are mainly responsible for the safety of students. They should study safety knowledge and safety regulations seriously. Parents should not let students take overloaded, speeding and unlicensed vehicles, and pay attention to traffic safety. If parents fail to comply with the requirements, students will be responsible for safety issues.
Six, parents or guardians should always remind students to pay attention to safety, and strengthen safety education, prohibit students from bathing or playing in rivers, rivers, ponds, weirs and pools.
Seven, when there is a safety accident in the park, parents or guardians should actively cooperate with the class teacher and take active measures to help the injured students.
8. If the following conditions are met, it can be concluded that the school is not at fault and irresponsible: (1) The damage incident has nothing to do with the school facilities, or although it is related to the school facilities, the school facilities are not defective; (two) the school or the teacher has fulfilled its due responsibilities in the education management, and the damage incident still inevitably occurs; (3) Students commit suicide, self-injury or accidental injury in antagonistic or dangerous sports competitions; (4) Other unexpected factors.
Nine, this responsibility from the date of signing, kept by the school.
Parent's signature:
Signature of class teacher:
_ _ _ _ school
_ _ _ _ _ _ _ _ _ _ _ _ _
Responsibility Letter for Building Safety (Part VI)
Party A: Qing Ji Branch of Shandong expressway Co., Ltd.
Party B: Project Department of Yin Qing expressway Relocation Project of Shandong Road and Bridge Construction Co., Ltd.
In order to ensure the safety of road construction site, passing vehicles and personnel, and put an end to safety accidents, based on the principles of "safety first, prevention first" and "whoever works is responsible", Party A and Party B reach an agreement and sign this responsibility letter:
1. construction project: relocation and widening project of Qingdao toll station in expressway, Yin Qing.
Two. Construction period: May 8, 2000 to July 2000 1.
Third, the requirements:
1. Party B shall abide by the civilized and safe construction regulations stipulated by Party A during the construction. Before the project starts, conduct safety training and education for the personnel involved in the construction, so as to familiarize them with the relevant safety operation procedures for working in expressway.
2. Before the project construction, Party B shall determine the traffic control plan according to the construction area, and report the specific location, sealing method and schematic diagram of the control area to Party A. ..
3, must be set up in line with the provisions of the state obvious construction signs.
4, the construction site must be set full-time security officer, responsible for the safety measures of the construction site.
5. Party B shall consciously accept the supervision and inspection of Party A, and promptly correct the violations proposed by Party A. Construction vehicles and personnel entering expressway must go through the formalities of road administration and traffic police management, and hold relevant certificates; Wear a reflective vest, or you are not allowed to enter expressway. Construction personnel shall not leave the safe operation area.
6. Party B shall pay a one-time deposit of RMB _ _ _ ten thousand Yuan to Party A, and if there is no violation of safety management regulations during the construction period, the deposit will be fully returned; However, in the following circumstances, the deposit shall be deducted accordingly:
(1) If violation of safety management is found, each person will be deducted 1000-5000 yuan.
(2) Failing to obey the correct dispatching command of Party A's management personnel, each person will be deducted 5000 yuan-10000 yuan.
(3) When Party A discovers Party B's violation of regulations, it will issue the Notice of Rectification of Violation of Regulations in expressway Construction Site to Party B, and deduct 1 10,000 yuan each time.
(4) Due to the serious traffic jam in expressway caused by Party B's construction, 30% of the total deposit will be deducted for each occurrence, except that it is ordered to stop work immediately for rectification.
(5) In the process of construction, Party B shall bear all responsibilities for accidents caused by Party B's construction or any loss or injury to passing vehicles and personnel, and Party A shall not bear any responsibilities, and deduct 20%-50% of the deposit.
(6) After deducting the deposit, Party B shall make up the deposit accordingly the next day.
Four. This agreement is made in quadruplicate, with each party holding two copies;
Five, since the date of signature and seal.
Person in charge of Party A:
Person in charge of Party B:
Date, year and month
Construction safety responsibility book (select 7 items)
In order to implement the policy of "safety first, prevention first, comprehensive management", according to the requirements of township party committees and governments for safe production, further straighten out the working mechanism of construction safety management, strengthen safety management, clarify the responsibility for construction safety, prevent and reduce unsafe accidents from the source, and formulate the responsibility book for target management in combination with reality.
1. For the project undertaken by the construction party, the national, municipal and county safety production guidelines, policies and regulations should be seriously implemented. Strictly implement the "three simultaneities" system of simultaneous design, simultaneous construction and simultaneous use of safety facilities in construction projects.
2. The project manager is fully responsible for the safety production of construction projects according to law, and is the first responsible person for safety production. It is necessary to establish and improve the safety production responsibility system and safety education and training system, formulate safety production rules and regulations and operating procedures, ensure the investment of funds needed for safety production conditions, conduct regular and special safety inspections on the construction projects undertaken, actively cooperate with the safety inspections of township safety supervision and management offices, and rectify the problems detected within a time limit.
3. The expenses for safe working environment and safety measures included in the budgetary estimate of construction projects shall be used for construction safety and shall not be used for other purposes.
4. The person in charge of the project must set up a safety production management organization with no less than 1 full-time safety production management personnel.
5. The person in charge of the project must establish a fire safety responsibility system at the construction site, determine the person responsible for fire safety, formulate various fire safety management systems and operating procedures such as using fire, electricity and inflammable and explosive materials, equip with fire-fighting equipment, and set up obvious safety warning signs at the construction site.
6. Achieve target management, strengthen the management of hidden dangers of accidents on the construction site, resolutely curb the occurrence of serious safety accidents and put an end to fatal accidents. In the event of a safety accident, the construction should be stopped immediately and rescue measures should be taken actively.
7. 15 Before the project starts, go through the filing formalities for the project start, accurately fill in the information such as the organization of unit engineering personnel, the investment in safe and civilized construction, the general plan of the construction site, etc., and report it to the Township People's Government for filing and approval before starting.
8. Go through the safety supervision formalities within 15 days before the project starts. At the same time, conduct safety assessment with the construction unit and supervision unit and sign an appointment for the cost of protective equipment. No work can be started without submitting a safety report to the prison.
9, tower crane before use must be submitted to the relevant departments for inspection, inspection qualified rear can use.
10. For other unspecified responsibilities, please refer to national, municipal and county laws and regulations on building safety management.
Seal of township government: _ _ _ _ _ _ _ Seal of construction unit: _ _ _ _ _ _
Signature of legal person of township government: _ _ _ _ _ _ signature of project leader: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date: _ _ _ _ _ _ _ _
Construction safety responsibility book (select 8 items)
Party A: _ _ _ _ _ _ _ _ Co., Ltd.
Party B: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
In order to strengthen the safety management of building construction, adhere to the policy of safety first and prevention first, and ensure safe production, it is everyone's responsibility to sign this safety responsibility book.
1. Party B must ensure that all personnel entering the site are at least 18 years old and in good health. Old, weak, sick, disabled, pregnant, family members, children and child laborers are not allowed to enter the site, otherwise all consequences will be borne by Party B, and Party A will not bear any responsibility.
2. All construction personnel of Party B must abide by the six disciplines of safe production stipulated by the state, abide by the safety management system of Party A and the provisions of civilized construction on site, and be familiar with and master the safety regulations and operation specifications of this type of work.
3. Party B and its team shall set up a leading group for safety construction, set up full-time safety officers to keep in touch with Party A, conduct safety education for its employees on a regular basis, conduct regular safety construction inspections (especially pre-shift education inspections), and sign safety responsibility letters with employees. If it fails to sign, all consequences arising therefrom shall be borne by Party B. ..
4. Party B must ensure that all employees use protective measures correctly according to regulations, and shall not abuse or use them; When entering the construction site, you must wear a safety helmet. Workers are forbidden to wear slippers, hard-soled shoes, permeable shoes and go to work shirtless. Operators of special types of work are required to hold relevant certificates, and it is forbidden to use those who are undocumented and do not understand electromechanical and equipment operation technology. In case of violation, all responsibilities shall be borne by Party B. ..
5. Party B's off-site construction personnel are prohibited from entering the construction planning area, otherwise all consequences will be borne by Party B personally.
6. During the construction period, all teams and individuals of Party B should enhance their safety awareness and do their own safety protection. Party B shall be responsible for all major and minor accidents, and Party A shall not be responsible. (Note: This clause is applicable to safety accidents caused by various reasons of Party B)
7. During the construction period, if Party B accidentally hurts others due to lax internal management, Party B shall bear all the responsibilities.
VIII. During the construction period, if Party B's personnel fight with other contractors, each contractor shall be responsible, and Party A will severely punish them according to the regulations on civilized construction on site.
Nine, Party B's construction personnel lost or any unsafe incidents, the responsibility shall be borne by Party B, and Party A shall not be responsible.
X party b's personnel or family members are not allowed to set up stalls, open canteens or sell non-staple food in the construction site and living quarters. Prevent food poisoning and accidents.
XI。 This responsibility book is made in quadruplicate, two for each party, as an annex to the project contract.
If there are any new clauses, they will be attached to this contract and have the same legal effect as this contract.
12. This contract shall come into effect as of the date of signature by both parties, and shall become invalid after the contract construction is completed and the payment is settled.
Party A: _ _ _ _ _ Co., Ltd. Person in charge: _ _ _ _ _ _ _ _
Party B: _ _ _ _ _ _ _ Person in charge: _ _ _ _ _ _ _
Date of signature: _ _ _ _ _ _ _ _ _