Post on 22-Apr-2020
Inviting sealed quotations from authorized firms/suppliers for Supply, Delivery,
Assembly, Installation & Operationalization and training thereof various handloom
based machineries and equipments for Balijana Dress Making & handicraft Cluster,
Goalpara, Assam
A. Bosco Reach Out is the Implementing agency for Balijana Dress Making & Handicraft
Cluster, Goalpara, Assam under the aegis of IIE as Nodal agency and EPCH clusters as the
technical agency for the SFURTI Project Ministry of MSME. Bosco Reach Out invites
sealed quotations affixing court fee stamps of Rs. 8.25 from authorized
vendor/firms/suppliers for supply, Delivery, Assembly and Installation &
Operationalization of various machineries and equipments at Balijana Dress Making &
Handicraft Cluster. Goalpara, Assam
B. General Details and Conditions
1. Description: Supply, Delivery, Assembly, Installation & Operationalisation of various
handloom machineries and equipments for Dress Making and Embroidery Products at
Balijana Dress Making & Handicraft Cluster. Goalpara, Assam.
2. Location: As specified in scope of work.
3. Price quoted will be inclusive of freight/transportation, taxes, charges, duty, transit
insurance and installation & operationalization.
4. Tender document may be downloaded from the website www.iietraining.org
5. Period of delivery and installation: 30 working days from the day receipt of work order.
6. The other terms and Conditions applicable to this tender have been incorporated in the
tender document.
7. The Competent Authority reserves the right to reject all or any tender wholly or partly
without assigning any reason whatsoever.
8. Earnest Money Deposit amounting to Rs. 1,89,340/- (for general) and Rs. 94,670/- (for
SC/ST) shall be submitted individually along with the offer.
9. Last date of submission the Tender Document: 12:00 pm 26-03-2020
10. Date & time of opening of tender: 03:00 pm 26-03-2020
11. If a Holiday falls on any of the schedule date then schedule date shall be considered on
next working day.
12. The tender should be submitted in accordance with the instructions and conditions and
any tender not conforming thereto is liable to be rejected. The instruction shall form the
part of the tender and contact. The tender shall be complete with all documents. The
tender received without tender fee shall be rejected outright.
13. The duly signed and stamped tender shall be submitted at the address: Director IIE ,
Lalmati, Guwahati-29/, Bosco Reach Out, BK Kakati Road, Bholanath Mandir Bye
Lane, Ulubari, Guwahati - 07 in a sealed envelope super scribing “SUPPLY,
DELIVERY, ASSEMBLY AND INSTALLATION & OPERATIONALIZATION
Indian Institute of Entrepreneurship
An ISO 9001:2015 Certified
Organization
Lalmati, N.H. Bypass No.37 Guwahati 29
Balijana Dress Making
& Handicraft Cluster,
Goalpara, Assam.
OF VARIOUS HANDLOOM MACHINERIES AND EQUIPMENTS AT
BALIJANA DRESS MAKING AND HANDICRAFT CLUSTER, GOALPARA,
ASSAM”. Including the following-
The forwarding letter of the tender.
Tender bid Proforma.
List as per Checklist (enclose as Annexure I).
14. Bidders must provide GST REGISTRATION CERTIFICATE else bids will be
automatically rejected.
15. Price quoted should be inclusive of GST.
C. Eligibility of the supplier:
1. Must have least 2 years of experience of supplying such items (Handloom and related
Machines)
2. Must have at least Rs 25 Lakhs of annual turnover from the supply business.
3. Must not be black listed by any agency from supplying of such items in the five years.
4. Must have experience of providing post sales services.
D. Scope of Work
I. Type of Work: Supply, Commissioning, & Installation and Operationalization of
following machines and equipments at Balijana Dress Making and Handicraft Cluster,
Goalpara, Assam.
II. (a) List of Machineries and equipments
Sl.
No Machine Name Technical Specification
Quantity
(in Nos)
Price
per
unit
Amount (Rs.
In Lakhs)
1 Jacquard Looms
Jacquard Machine Wood Frame,
Small Naraj, Big Naraj (Length 6.5ft
weidth 5ft), Slea (Bonsom Kath),
General Jacquard Machine (Duby)
120/160 no; Steel Reed, Bao(Jakin),
Dahi, Putal, Piker Nachani, Muthi,
Sirakh/ Harnish, Garka, Sunga
(Bamboo), Nata, Frame (Dig/ Bani),
Flay Sattle, Hand Sattle, Steel Bar,
Khela, Muthi Rope, Spinner (Hand
Jotor), Bobin, Pen (Mohura), Ball
Bearing machine. (preferably Aahu,
Titasafa, Bonsoom, Sal and
Segonkath)
2
52" fly shuttle frame loom set 52 "
R.S. Fly shuttle frame loom with 6
post ,Complete with weavers seat ,
heald frame , treadle - 2 nos , pulley
bar , pulley (4 nos), beams ,front &
back rest , 1.5 ' of 10 mm and 8 mm
rods for tightening / fixing of
tradle and beams during weaving .
The looms should be of following
specifications. ( Loom should be
fitted with Nut & bolt )
1. front post - 4"x4"x 6.5 ' of
seasoned Sal wood
2.Middle post - 3 " x 4 "x 6.5' of
seasoned Sal wood
3. Back post - 4"x4"x 3.0 ' of
seasoned Sal wood
4.weavers seat- 1.5" x 8" of
seasoned Sal wood
5. Treadle - 1" x 1.5" of seasoned
Sal wood, suitable for 52 " RS
loom
6. Side Bars of standard size of
seasoned Sal / Bansoom wood.
7. beams - Round cloth beam of
8.5" & hexagonal warp beam of
11.5" in circumference of seasoned
Sal / Bansoom wood along with the
following kit.
* 1 set of Complete set of Sley with
all allied accessories suitable for 52"
RS Fly shuttle frame loom ,made of
Bonsoom wood only. Shuttle gurd
should be screwed so that it can be
opened to change the picker
whenever needed
* 1 no. of Reed (52 s x 52" )
* 1 No. of Handloom Shuttle of
12.5 " in length for suitable for
weaving silk and cotton
* 1 Set of Country heald (Set of
2160 healds or "21 pone") made of
2.0 number nylon thread
* 1 No. of Coats gun ( Cotton
threads reel of 800 mts.)
* 1 kg of Cotton rope (fine quality )
* 1 No. of Drawing hook (Brass)
* 1 No. of Drawing hook (iron)
* 12 No. of Plastic pirn of 4"- 4.5"
in length
* 12 No. of Bobbin 6" x flange 1.5
' in diameter
* 2 Sets of 52" long aluminum lease
rod (set of 4 pcs)
2
* 1 No. of Design shuttle (made of
teteli wood )
* 1 No. of Cycle wheel charkha
* 1 No. of Cherki made of bamboo
* 1 No. of Wooden Cherki Stand
* 1 Set of wooden temple for 52 "
RS Loom
* 1 Set of Plastic Pulley (set of 12
pcs)
* 1 No. of Reed Brush (Glass fibre)
2 Warping Drum
Sal Kath/ Best Quality wood
5
5 meter
3 Dyeing
Accessories
Fabcare Stack Washer Dryer (15
Kg Capacity Each - Electrically
Heated) Spotting machine with 2
spotting guns, suction blower.
excellent for spotting. (without
compressor)
1
4 Reeling/Spinning
Machine
One set of Machine should consists
of (Coarsa Fillet-Motorized-One
No., Fine Fillet-Motorized-One,
Tape Draw Frame-Motored-One
Roving Frame-Motorized-One)
3
5 Calendaring
Machine
Machine is used for calendering and
finishing to cloth. It also gives
original size to the cloth which is
shrinked while Dyeing, it also made
M.S. Channel fixed with four roller
with side roller and side stand
1
6 Industrial Sewing
Machine
(Industrial Direct Drive Sewing
Machine, Internationally Known
Brand), Minimum: Sewing speed
5000 sti/min, Needle bar stroke-
30.7mm, Feed dog height: 0.8mm,
Needle- DBx1 (#11), #9-18, (Nm65-
110), Lift of the presser foot- by
hand: 5.5mm, By Knee: 15mm,
Auto: 8.5 mm, Size of bed-
517x178mm (distance from needle
to machine arm: 303mm), Bobbin
thread winder- built- in the machine
head, machine head drive- Compact
AC servomotor (450W) that is
directly connected to the main shaft
(direct-drive system), Automatic
reverse feed function- yes.
5
7 Manual Sewing Number of Stitches-31, Sewing 14
Machine Speed-860 SPM, Maximum Stitch
width- 5 mm, Maximum stitch
Length- 4 mm, built-in-needle
threader, automatic thread cutter
(Usha/ Singer )
8 Bobbin Winding
Machine
Should be Internationally Known
Brand, Good Quality 1
9
Distribution of
Looms and
Handicraft Tools
52" fly shuttle frame loom set with
Jacquard attachment.
52" fly shuttle frame loom set 52 "
R.S. Fly shuttle frame loom with 6
post ,Complete with weavers seat ,
heald frame , treadle - 2 nos , pulley
bar , pulley (4 nos), beams ,front &
back rest , 1.5 ' of 10 mm and 8 mm
rods for tightening / fixing of
tradle and beams during weaving .
The looms should be of following
specifications. ( Loom should be
fitted with Nut & bolt )
*1. front post - 4"x4"x 6.5 ' of
seasoned Sal wood
* 2.Middle post - 3 " x 4 "x 6.5' of
seasoned Sal wood
*3. Back post - 4"x4"x 3.0 ' of
seasoned Sal wood
* 4.weavers seat- 1.5" x 8" of
seasoned Sal wood
*5. Treadle - 1" x 1.5" of seasoned
Sal wood, suitable for 52 " RS
loom
*6. Side Bars of standard size of
seasoned Sal / Bansoom wood.
*7. beams - Round cloth beam of
8.5" & hexagonal warp beam of
11.5" in circumference of seasoned
Sal / Bansoom wood along with the
following kit.
* 1 set of Complete set of Sley with
all allied accessories suitable for 52"
RS Fly shuttle frame loom ,made of
Bonsoom wood only. Shuttle gurd
should be screwed so that it can be
opened to change the picker
whenever needed
* 1 no. of Reed (52 s x 52" )
* 1 No. of Handloom Shuttle of
250
12.5 " in length for suitable for
weaving silk and cotton
* 1 Set of Country heald (Set of
2160 healds or "21 pone") made of
2.0 number nylon thread
* 1 No. of Coats gun ( Cotton
threads reel of 800 mts.)
* 1 kg of Cotton rope (fine quality )
* 1 No. of Drawing hook (Brass)
* 1 No. of Drawing hook (iron)
* 12 No. of Plastic pirn of 4"- 4.5"
in length
* 12 No. of Bobbin 6" x flange 1.5
' in diameter
* 2 Sets of 52" long aluminum lease
rod (set of 4 pcs)
* 1 No. of Design shuttle (made of
teteli wood )
* 1 No. of Cycle wheel charkha
* 1 No. of Cherki made of bamboo
* 1 No. of Wooden Cherki Stand
* 1 Set of wooden temple for 52 "
RS Loom
* 1 Set of Plastic Pulley (set of 12
pcs)
* 1 No. of Reed Brush (Glass fibre)
10
Storage facility
Almirah (Steel and style) : Gauge –
20”, Width – 36”, Depth – 20”,
Height 77”
4
Reck (Steel and style): 18”D x 36”
W
Angles 8” height
4
11 Office Accessories
2 Showcase
4 office Table - Steel and style
4 Revolving chair
40 plastic chair – Supreme Made
1 Green board (6 ft x 4 ft)
1 File cabinet (2 drawer) - Steel and
style
LS
12 Other Accessories
1 Laptop (Intel Core i3 7th Gen,
15.6 inch FHD Laptop,8Gb/1TB
HDD / Windows 10 + MS office) 1
Printer/Scanner (Low cost Printing,
Compact size, shorter setup time,
wireless connectivity, document
removal reminder, Auto document
feeder and auto duplex printing,
with 1 tank ink).
LS
Total Estimated Cost
Packing, transportation and installation & operationalization of the Machines:
The successful bidder shall be responsible for packing, transportation; installation &
operationalization and trail run of the machineries and equipments as per the following:
a) The agency has to pack and transport the machines to the various clusters at Balijana
Dress Making Cluster, Goalpara.
b) The agency shall install and demonstrate trail run of the machines at the Balijana Dress
Making Cluster, Goalpara.
TRAINING: The bidder should impart suitable training to a group of cluster artisans
for operation and maintenance of the machines during installation at the cluster site
and if required separate training programme can be arranged with separate financial
consideration.
SPARES: The agency has to provide required spare parts as and when required for at
least 2 year as per the market price. The percent market price of the share part shall be
mentioned along with the quotation.
SERVICES: The agency must be able to provide post sale services as and when
required with a separate
Fee as per the market rate.
MRLS & MANUALS: The supplier has to include manufacturer recommended list
of spares & cost thereof for 2 years successful running of machine in their quotation.
However the same will not be considered for finalization of order.
SELECTION CRITERIA: The technical score of the agency will be evaluated
based on the above mentioned criteria and the agency has to score 50% of the
technical score. The evaluation criteria is as follows:
SI No Criteria Full score
1
Experience of supplying handloom related machines
>2 years – 20 point
1-2 year – 10 points,
<1 year – 0
20
2
Annual turnover from the supply business
>Rs 100 Lakh – 20
Rs 100- 50 Lakhs – 10
Rs 50 – 25 Lakhs – 5,
<25 Lakh – 0
20
3
Experience of providing post sales services
>2 years – 10
2-1 year – 5
<1 year – 2.5,
No experience – 0
10
4 Total 50
5 Eligible score of opening financial bid 25/50
GUARANTEE: Supplier should give Bank guarantee 5% of quoted amount valid till
period of work order for satisfactory performance of machines as per company norms
from the date of successful installation of the machines.
Forwarding Letter Format
(To be provided in the official letter head of the bidder)
To,
Executive Director
Bosco Reach Out
Ulubari, Guwahati – 07, Assam
Sub: Supply, Delivery, Assembly, Installation and Operationalization of various
machineries and equipments at Balijana Dress Making and Handicraft Cluster, Goalpara,
Assam.
Dear Sir/Madam,
With reference to the tender notification, we hereby submit our technical credibility and
financial quotation for supplying of the listed machines. We agree that the tender
document provided are true to our knowledge and sprit and if found incorrect, our
application will be cancelled automatically and we are ready to provide the required bank
guarantee for the supply/against the advance amount.
(Signature)
Date
Official Seal
Technical Bid Document
SI No Criteria List of enclosed
Supporting
documents
1 Experience of supplying loom processing
machines- supply order copies YES
NO
2 Annual turnover from the supply business –
annual audit reports for last two Years (2017-
18 & 2018-19)
YES
NO
3 Experience of providing post sales services-
order copies YES
NO
SL
No
Type of Document Please Tick
4 The forwarding letter of the tender YES
NO
5 Technical bid document YES
NO
6 Supporting for technical bid YES
NO
7 Financial bid document YES
NO
8 Certificate of registration/proof of ownership
along address YES
NO
9 Copy of Pan card/TIN YES
NO
10 GST registration YES
NO
11 Income tax return, Audited balanced sheet for last
two years(2017-18 & 2018-19) YES
NO
12 Undertaking that the firm is not blacklisted by
any government/private Organisation YES
NO
13 Undertaking that the firm has no pending
vigilance/ CBI case, YES
NO
14 Certificate that the firm is not supplying the same
item at lower rates quoted in the tender to any
government institution during the past one year ,
as per fall clause adhered by DGS/D and other
government Organisation.
YES
NO
*Compulsory
(Signature)
Date:
Office Seal
Financial bid document
To,
Executive Director
Bosco Reach Out
Ulubari, Guwahati – 07, Assam
Sub: Financial quotation for supply, delivery, Assembly, Installation & Operationalization of
various machineries and equipments at Balijana Dress Making and Handicraft Cluster,
Goalpara, Assam.
Dear Sir/Madam,
Please find the best possible quotation for supply of the listed items as follows:
Sl.
No Machine Name Technical Specification
Price at Balijana,
Goalpara (including tax,
packaging, transport,
Installation & trial run)
1 Jacquard Looms
Jacquard Machine Wood Frame,
Small Naraj, Big Naraj(Length 6.5ft
weidth 5ft), Slea(Bonsom
Kath),General Jacquard Machine
(Duby) 120/160 no; Steel Reed,
Bao(Jakin), Dahi, Putal, Piker
Nachani, Muthi,
Sirakh/Harnish,Garka,
Sunga(Bamboo),Nata,
Frame(Dig/Bani),Flay
Sattle,HandSattle,SteelBar,Khela,
MuthiRope,Spinner(Hand
Jotor),Bobin,Pen(Mohura),Ball
Bearing machine.(preferably
Aahu,Titasafa, Bonsoom, Sal and
Segonkath)
52" fly shuttle frame loom set 52 "
R.S. Fly shuttle frame loom with 6
post ,Complete with weavers seat ,
heald frame , treadle - 2 nos , pulley
bar , pulley (4 nos), beams ,front &
back rest , 1.5 ' of 10 mm and 8 mm
rods for tightening / fixing of tradle
and beams during weaving . The
looms should be of following
specifications. ( Loom should be fitted
with Nut & bolt )
1. front post - 4"x4"x 6.5 ' of
seasoned Sal wood
2.Middle post - 3 " x 4 "x 6.5' of
seasoned Sal wood
3. Back post - 4"x4"x 3.0 ' of
seasoned Sal wood
4.weavers seat- 1.5" x 8" of seasoned
Sal wood
5. Treadle - 1" x 1.5" of seasoned
Sal wood, suitable for 52 " RS loom
6. Side Bars of standard size of
seasoned Sal / Bansoom wood.
7. beams - Round cloth beam of 8.5"
& hexagonal warp beam of 11.5" in
circumference of seasoned Sal /
Bansoom wood along with the
following kit.
* 1 set of Complete set of Sley with
all allied accessories suitable for 52"
RS Fly shuttle frame loom ,made of
Bonsoom wood only. Shuttle gurd
should be screwed so that it can be
opened to change the picker whenever
needed
* 1 no. of Reed (52 s x 52" )
* 1 No. of Handloom Shuttle of 12.5
" in length for suitable for weaving
silk and cotton
* 1 Set of Country heald (Set of 2160
healds or "21 pone") made of 2.0
number nylon thread
* 1 No. of Coats gun ( Cotton threads
reel of 800 mts.)
* 1 kg of Cotton rope (fine quality )
* 1 No. of Drawing hook (Brass)
* 1 No. of Drawing hook (iron)
* 12 No. of Plastic pirn of 4"- 4.5" in
length
* 12 No. of Bobbin 6" x flange 1.5 '
in diameter
* 2 Sets of 52" long aluminum lease
rod (set of 4 pcs)
* 1 No. of Design shuttle (made of
teteli wood )
* 1 No. of Cycle wheel charkha
* 1 No. of Cherki made of bamboo
* 1 No. of Wooden Cherki Stand
* 1 Set of wooden temple for 52 " RS
Loom
* 1 Set of Plastic Pulley (set of 12
pcs)
* 1 No. of Reed Brush (Glass fibre)
2 Warping Drum Sal Kath/ Best Quality Wood
5 meter
3 Dyeing
Accessories
Fabcare Stack Washer Dryer (15 Kg
Capacity Each - Electrically Heated)
Spotting machine with 2 spotting
guns, suction blower. excellent for
spotting. (without compressor)
4 Reeling/Spinning
Machine
One set of Machine should consists of
(Coarsa Fillet-Motorized-One No.,
Fine Fillet-Motorized-One, Tape
Draw Frame-Motored-One Roving
Frame-Motorized-One)
5 Calendaring
Machine
Machine is used for calendering and
finishing to cloth. It also gives original
size to the cloth which is shrinked
while Dyeing, it also made M.S.
Channel fixed with four roller with
side roller and side stand
6 Industrial
Sewing Machine
(Industrial Direct Drive Sewing
Machine, Internationally Known
Brand), Minimum: Sewing speed
5000 sti/min, Needle bar stroke-
30.7mm, Feed dog height: 0.8mm,
Needle- DBx1 (#11), #9-18, (Nm65-
110), Lift of the presser foot- by hand:
5.5mm, By Knee: 15mm, Auto: 8.5
mm, Size of bed- 517x178mm
(distance from needle to machine arm:
303mm), Bobbin thread winder- built-
in the machine head, machine head
drive- Compact AC servomotor
(450W) that is directly connected to
the main shaft (direct-drive system),
Automatic reverse feed function- yes.
7 Manual Sewing
Machine
Number of Stitches-31, Sewing
Speed-860 SPM, Maximum Stitch
width- 5 mm, Maximum stitch
Length- 4 mm, built-in-needle
threader, automatic thread cutter
(Usha/ Singer )
8 Bobbin Winding
Machine
Should be Internationally Known
Brand, Good Quality
9
Distribution of
Looms and
Handicraft Tools
52" fly shuttle frame loom set with
Jacquard attachment.
52" fly shuttle frame loom set 52 "
R.S. Fly shuttle frame loom with 6
post ,Complete with weavers seat ,
heald frame , treadle - 2 nos , pulley
bar , pulley (4 nos), beams ,front &
back rest , 1.5 ' of 10 mm and 8 mm
rods for tightening / fixing of tradle
and beams during weaving . The
looms should be of following
specifications. ( Loom should be fitted
with Nut & bolt )
*1. front post - 4"x4"x 6.5 ' of
seasoned Sal wood
* 2.Middle post - 3 " x 4 "x 6.5' of
seasoned Sal wood
*3. Back post - 4"x4"x 3.0 ' of
seasoned Sal wood
* 4.weavers seat- 1.5" x 8" of
seasoned Sal wood
*5. Treadle - 1" x 1.5" of seasoned
Sal wood, suitable for 52 " RS loom
*6. Side Bars of standard size of
seasoned Sal / Bansoom wood.
*7. beams - Round cloth beam of 8.5"
& hexagonal warp beam of 11.5" in
circumference of seasoned Sal /
Bansoom wood along with the
following kit.
* 1 set of Complete set of Sley with
all allied accessories suitable for 52"
RS Fly shuttle frame loom ,made of
Bonsoom wood only. Shuttle gurd
should be screwed so that it can be
opened to change the picker whenever
needed
* 1 no. of Reed (52 s x 52" )
* 1 No. of Handloom Shuttle of 12.5
" in length for suitable for weaving
silk and cotton
* 1 Set of Country heald (Set of 2160
healds or "21 pone") made of 2.0
number nylon thread
* 1 No. of Coats gun ( Cotton threads
reel of 800 mts.)
* 1 kg of Cotton rope (fine quality )
* 1 No. of Drawing hook (Brass)
* 1 No. of Drawing hook (iron)
* 12 No. of Plastic pirn of 4"- 4.5" in
length
* 12 No. of Bobbin 6" x flange 1.5 '
in diameter
* 2 Sets of 52" long aluminum lease
rod (set of 4 pcs)
* 1 No. of Design shuttle (made of
teteli wood )
* 1 No. of Cycle wheel charkha
* 1 No. of Cherki made of bamboo
* 1 No. of Wooden Cherki Stand
* 1 Set of wooden temple for 52 " RS
Loom
* 1 Set of Plastic Pulley (set of 12
pcs)
* 1 No. of Reed Brush (Glass fibre)
10
Storage facility
Almirah (Steel and style) : Gauge –
20”, Width – 36”, Depth – 20”, Height
77”
Reck (Steel and style): 18”D x 36” W
Angles 8” height
11 Office
Accessories
2 Showcase
4 office Table - Steel and style
4 Revolving chair
40 plastic chair – Supreme Made
1 Green board (6 ft x 4 ft)
1 File cabinet (2 drawer) - Steel and
style
12 Other
Accessories
1 Laptop (Intel Core i3 7th Gen, 15.6
inch FHD Laptop,8Gb/1TB HDD /
Windows 10 + MS office) 1
Printer/Scanner (Low cost Printing,
Compact size, shorter setup time,
wireless connectivity, document
removal reminder, Auto document
feeder and auto duplex printing, with
1 tank ink).
(Signature)
Date
Official Seal
ANNEXURE-I
Checklist
SL No Type of Document Please Tick
1 The forwarding letter of the tender YES
NO
2 Technical bid document YES
NO
3 Supporting for technical bid YES
NO
4 Financial bid document YES
NO
5 Certificate of registration/proof of ownership along address YES
NO
6 Copy of Pan card/TIN YES
NO
7 GST registration YES
NO
8 Income tax return, Audited balanced sheet for last three Years YES
NO
9 Undertaking that the firm is not blacklisted by any
government/private Organization
YES
NO
10 Undertaking that the firm has no pending vigilance/ CBI case, YES
NO
11 Certificate that the firm is not supplying the same item at lower
rates quoted in the tender to any government institution during
the past one year , as per fall clause adhered by DGS/D and other
government Organization.
YES
NO
*Compulsory
(Signature)
Date
Official Seal