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ffitqrfrTrtr*rnfrrrr,rt* *; 1-ran d?rFr{r, rFa qr{6rt)EMPLOYEES' STATE INSURANCE CORPORATION(Ministry of Labor & Employment, Govt. of lndla)

fi. rt.*.ft. src* rrqara q" q{srq ffnI {III itiq-frqqf,{, wreq.e, frsa.z, sq.}fl{$dl, rri-dihl$E{,ffirooosr.ESIC Model Hospital Cum Occupational Disease CenlFanchdeep Bhavan, Plot tlo.g Road No..7, MIOC, MarolAndherl East, Murnbai400093, Emeil: ms.andheri,mh@esic nrr

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Medical Superintendent, ESIC Model Hospital Andheri extended expression ofinterest (EOl) from CGHS/Govt /Semi go\t approved / private Blood banks and

intencls to enter in to a Tie-up arrangement with reputed Blood banks to provide'Whole Blood' and'Blood Products'on cash less basis to the beneficiaries of ESICAndheri and Kandivali based at ESIS Hospital Kandivali

The services are to be prr:vided at CGHS rates (given on its website) and as

perterms and conditions available with our EOI notice at website \!.'i,r\r esic 1llc t!l/tenders and the form can be downloaded from the above site,

Prior Schedule: -

Last date of submission 4A/fi/2021up to 1 pm at Dy. M,S, office, 2ndfloor

ESIC ital. Kandivali (East

3017U2027 at 2.30 pm

Bxtended Schedule

Submission of EOI forrn Last date of submissian -I5/L2/2027up to 1 pm at Dy. M.S. office, 2ndfloor

ESIC Hos Kandivali (Ea

of EOI t5/L2/2OZL at 2.30

Interested may ref'er to the website tvww.esic n-is,i-&r^[gndg6 lbr the details for EligibilityConditions.

a;^ -,'tt (ul\-rMedial Suferintendent

Submission of EOI form

gpenins of EOl

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fiffi{r.'-q+firfrrrfi(rrs w rirrm riTrilq, grra rrqrt)

i EMPLOYEES' STATE INSURANCE CORPORATIONr [Uinistry of Labor & Employment, Govt. of lndia)

6'. rT.*.fr. srrqct 3rrrrm sd'q{srq Fq fir *a{qfrqr+q, wrdq.e, rtsc.z, q{qT{dS, Tfr-doitfr$,1ffi+ooosa.ESIC Model Hospital Cum Occupational Disease CentrePanchdeep Bhavan, Plot No.g Road No..7, MIDC, MarolAndheri East, Mumbai-400093.Phone: 022-28225568/69 Email: ms-andheri.mh@esic.nic.rnWebsite: www.esic.nic.in / www.esic.in

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No. EMHA/SST Cell/Blood Bank/Tender File/201 8/ Date-1511112021

Medical Superintendent ESIC Model Hospital Andheri, invites expression ofinterest (EOI) from CGHS/Govt /Semi govt approved / private Blood banks and

intends to enter in to a Tie-up arangement with reputed Blood banks to provide'Whole Blood' and 'Blood Products' on cash less basis to the beneficiaries ofESIC Andheri and Kandivali based at ESIS Hospital Kandivali.

The services are to be provided at CGHS rates (given on its website) and as

perterms and conditions available with our EOI notice at website www.esic.nic.in/tenders and the form can be downloaded from the above site.

Schedule: -

Duration of asreement: Duration of asreement shall be for a neriod of tw<l

years extendable for one year at the sole discretion of Medical SuperintendentESIC Andheri subject to fulfilment of all terms and conditions and with mutualconsent.

III) along with self-attested photo copies of all relevantcertificates/documents etc.(all duly signed) latest by the date as specifiedabove.

Bank Empanelment along with Name and Complete Address of theBlood Bank Centre. Addressed to Medical Superintendent, ESICAndheri based at ESl,Kandivali (East)

) tate Applications i.e. received after the specified date and time of receiptwillnot be considered.

withoutassigning any reason thereof.

Submission of EOI form Last date of submission 30/11./2021.up to 1 pm at Dy. M.S. office, 2ndfloor

ESIC Hospital, Kandivali (East)

Openins of EOI 30/11.1202t at 2.30 pm

Page 1 of 19

Soecial terms and conditions for blood bank:

-

The Centre should have necessary facilities for round the clock (24 hours)

supply of the Whole Human Blood and various blood components.

The Centre should have the necessary and valid license from the appropriate

authority to run the Blood Bank.

Under the tie-up arangement, the requisition shall be made on the 'oin house

standard form" duly signed by the attending doctor of hospital, and

countersigned by the casualty medical offtcer (CMO) lDy. Medical

Superintendent / Medical Superintendent with the rubber stamp of the hospital,

and shall contain particulars of units of Blood or blood components, name ofthe patient, Insurance number of the Insured person (IP) patient as well as the

MRD No. /Inpatient NolBed No, along with provisional diagnosis. Anyrequisition form sent to you not in prescribed manner, as stated above is not to

be considered by your Blood bank / office and no claim shall be accepted

unless the requisition as aforesaid is received.

The whole Human Blood and Blood components should be screened for allroutine and special investigations including Blood grouping, Typing, Cross

Matching and other standard as well as specialized tests for HIV, Hepatitis, etc.

as specified by competent authority in this regard.

Bills should be sent monthly in triplicate and should be accompanied by acopy of each of the requisition forms.

Officers authorized by the Hqrs. Office / Office of Medical superintendent

Kandivali may visit the empaneled center at any time and if any irregularitynoticed then necessary action may be initiated as deemed fit.The services should be made available round the clock on all days.

If hospital authority certiff emergency/lifesaving requirement of.human blood

and blood components blood bank must provide same without donation.

Page 2 of 19

Criteria for selection of Blood Bank:

L FDA approved.2. SBTC approved.

3. Supply of blood at CGHS rate.4. Valid Bio Medical License.5. Valid Pollution Control Board License.6. Storage facility.7. Component facility - Yes / No. (if applicable)8. Reservation of blood should be done for at least 48 hrs.9. Cold chain maintenance.10" Open on all days 24*7 .

I 1. ESI Registration (if applicable)t2.1. Performance Bank Guarantee:

The Empaneled center shall furnish a Perfornance Bank Guarantee/DD fromany Nationalized Bank in the prescribed format Rupees Fifty thousand valid fora period of 3(Three) years to ensure efficient service and to safeguard againstany default.

2. Forfeiture of performance bank guarantee and removal from list ofempaneled institutions :

In case of any violation of the provisions of this Agreement by the Blood Banksuch as:

empaneled.

data in the report.

any stage and violation of Terms and Condition of EOI Published for thisempanelment.

The Medical Superintendent ESIC Hospital Andheri will have the full right to forfeitthe Performance bank guarantee as well as removal of Empaneled center from the listof empaneled institution. Such action could be initiated on the basis of a complaint oron the above points (a to g) by the Medical Superintendent as the case may be and

Page 3 of 19

decision of Medical Superintendent ESIC Andheri in this regard shall be final and

binding to EmPaneled center

1. DEFINITION & INTERPRETATIONS: -

1.1. The following terms and expressions shall have the following meninges for

pu{pose of this agreement.

1.1.1 .,Agreement" shall mean this agreement and all schedules, supplements,

appendices, appendages and modifications thereof made in accordance with the terms

of this agreement.

1.1.2..Benefit" shall mean the extent or degree of services the beneficiaries are

entitled to receive as per rules on the subject'

1.1.3 ,'Card" shall mean the ESI Card, issued by the competent Authority of ESIC'

l.l.4 "Card Holder" shall mean a person having an ESI card'

1.1.5 ,.E,SI Beneficiary" shall mean a person who is eligible for coverage of ESI and

hold a valid ESI card for the benefit'

I .1 .6 ,.Cov erage" shall mean the persons eligible as beneficiaries of the Employee

State Insurance Scheme, Maharashtra.

1 .1.7 ,,Empanelment" shall mean the Blood Bank authorized by the ESI for supply of

Blood and Blood products for a particular period'

1.1.g ,,Blood Bank" blood bank shall mean empaneled blood bank providing blood

and blood products to ESI Beneficiaries'

1.1.9 ,.Recognition of Blood Bank" shall mean the Blood Bank empaneled by the E'SI

for a particular period for providing treatment facilities and procedure etc. to the ESI

beneficiaries at the CGHS rates.

1,1.10 ,,De-recognition of Blood Bank" shall mean debarring the Blood Bank on

account of adopting unethical practices or fraudulent means in providing whole Blood

and Blood products or not following the good industry practices of the health care for

the ESI beneficiaries after followings certain procedure of enquiry verification'

Party" shall mean the ESIC or the and "Parties

" shall mean both the ESIC and the

l..l.l2Annexure-1, II shall be deemed to be an integral part of this Agreement'

Page 4 of 19

2. SERVICE AREA

The blood bank shall provide blood and components to the ESI beneficiaries at ESISHospital, Kandivali (E) Mumbai.

3. SERVICB CHARGES

The Blood bank shall charge as per the rates for a particular product deal as prescribedby the CGHS, Mumbai and attached as Annexure which shall be an integral part ofthis agreement.

4. DURATION

The Agreement shall remain in force for a perio d of 2year or till it is modified orrevoked, whichever is earlier. The Agreement may be extended for subsequent periodsas required by ESIC, subject to fulfilment of all the terms and conditions of thisAgreement and with mutual consent.

5. MEDICAL AUDTT OF BILLS

The medical audit of the bills of the Blood Bank will be conducted by the ESIC or anyauthority designated by ESIC for that pufpose within 90 days of submission of bills.

6. GENERAT CONDITIONS

6.1 Duly filled and signed and stamped requisition form by designated Specialist /Medical Officer i) for issue of Blood, and ii) for booking of Blood and Bloodcomponents shall be treated as valid requisition.

6.2 While issuing the Blood/Blood component required maintenance oftemperature will be taken care of by the issuing center i.e. Blood bank

6.3 For Planned surgeries " Requisition for booking " of Blood or Blood productsshall be treated only as "booked product" for next 48 hours from the date and time ofsubmission of requisition form,

6.4 Once Blood/ Blood products is issued it is understood that even in case nonuseit cannot be taken back by Blood Bank,

6.5 No Blood/ Blood products are expected to be issued without properly signed

"Requisition form" per Annexure II

6.6 Grouping and cross matching shall be the responsibility of Blood Bank,(Empaneled Centre).

Page 5 of 19

6.7 "Blood Requisition Form" shall be issued in two copies from ESI Hospital. One

such copy will be (with due entries) returned with issued products.

6.g The Blood Bank copy of "Requisition form for issue "is to be submitted with the

claimed bill (month wise)

6.9 The Blood Bank is expected to submit the claimed bill every month for settlement

of claim.

6.10 No additional charge will be claimed from the beneficiaries who have reached

the "Blood Bank" with duly filled " Requisition form for issue,

6.1 1 In case of additional requirement of Blood/ Blood product, booking of additional

units can be done telephonically through the office of CMO, ESI Hospital, Kandivali

but before collection of such demand requisite demand form will he submitted at the

blood bank.

7. DUTIES AND RESPONSIBILITIES OF BLOOD BANKS/

CENTBRS

It shall be the duty and responsibility of the Blood Bank at all times, to obtain,

maintain and sustain the valid registration, recognition and high quality and

standard of its services and Blood/ Blood product and to have ail statutory

mandatory licenses, permits or approvals of the concerned authorities under or as

per the existing laws.

8. Blood Bank /centre's integrity and obligations during agreement

period:

The Blood Bank is responsible for and obliged to conduct all contracted activities

in accordance with the Agreement, using state-of-the-art methods and economic

principles and exercising all means available to achieve the performance specified

in the Agreement. The Blood Bank is obliged to act within its own authority and

abide by the directives issued by the ESIC. The Blood Bank is responsible for

managing the activities of its personnel and will hold itself responsible for their

misderneanors, negligence, misconduct or deficiency in services, if any'

*t

Page 5 of 19

9. Liquidated damages:

g.1 The Blood Bank shall provide the services as per the requirements specified

by the ESIC in terms of the provisions of this Agreement. In case of initial

violation of the provisions of the Agreement by the Blood bank, such as

refusal of service or direct charging form the ESI beneficiaries or defective

service and negligence, the complaint will be examined by the ESI

authorities and if the complaint is found to be true the ESIC shall have the

right to give a show cause notice to the Blood bank to be replied by it within

10 days of its receipt and the reply of the Blood Bank will be examined by

a committee constituted for the purpose of deciding the'appropriateness

services, as the case may be, If the Committee concludes that the Blood

Bank has violated the provisions of the agreement necessary action will be

taken as deemed. The decision of the ESI will be final,

9.2 For over-billing, the extra amount so charged will be deducted from the

pending / future bills of the Blood Bank and the ESIC shall have the right to

issue a written warning to the Blood Bank not to do so in future. The

recuffence, if any, will lead to the stoppage of referral to that Blood Bank.

l2

Page 7 of 19

10. Termination for default:

10.1The Employee State Insurance Corporation, without prejudice to any

other remedy for breach of Agreement, by written notice of default sent to

the Blood Bank can terminate the agreement in whole or part:

A. If the Blood Bank fails to provide any or all of the services for which it has

been empaneled within the period(s) specified in the Agreement, or within

any extension period thereof if granted by the ESIC as the case may be.

Pursuant to condition of agreement, or

B. If the Blood Bank fails to perform any other obligation(s) under the

Agreement. Or

C. If the Blood Bank, in the judgment of the ESIC is engaged in corrupt or

fraudulent practices in competing for or in executing the Agreement'

D. If the Blood Banks fails to follow instruction & guidelines and there is

repeated submission of bills as per its own way with repeated deficiencies

etc.

l0.2lf the Blood Bank is found to be involved in or associated with any

unethical illegal or unlawful activities, the Agreement will be summarily

terminated by ESIC without any notice and thereafter may terminate the

agreement, after giving a show cause notice and considering its replay if any,

received within 10 days of the receipt of show cause notice.

10.3In case of any violation of the provisions of the agreement by the Blood

bank such as (but not limited to) refusal of service, refusal of credit facilities

to eligible beneficiaries and direct charging form the ESI beneficiaries,

deficient of defective service, over billing and negligence in up keep of

Blood and Blood products, the ESIC shall have the right to terminate the

conduct.

Page 8 of 19

11. INDEMNITY

The Blood Bank shall at all times, indemnitr and keep indemnified ESIC againstall actions, suits, claims and demands brought or made against it in respect ofanything done or purported to be done by the Blood Bank in execution of or inconnection with the services under this Agreement and against any loss ordamage to ESIC in consequence to any action or suits being brought against theESIC, along with (or otherwise), Blood Bank as a party for anything done orpurported to be done in the course of the execution of this Agreement. The BloodBank will at all times abide by the job safety measures and other statutoryrequirements prevalent in India and will keep free and indemnify the ESIC fromall demands or responsibilities arising from accidents or loss of life, the cause orresult of which is the Blood Bank negligence or misconduct. The Blood Bankwill pay all indemnities arising from such incidents without any extra cost toESIC and will not hold the ESIC responsible or obligated, The ESIC may at ftsdiscretion and shall always be entirely at the cost of the Blood Bank defend suchsuits, either jointly with the Blood Bank or singly in case the latter chooses notto defend the.

12. ARBITRATION

If any dispute of difference of any kind whatsoever shall be

the provisions of the Arbitration and conciliation Act. 1996

arbitration proceedings. The venue of the arbitration process

Mumbai or as decided by the appellate authority.

entertaihed under

shall apply to the

dings shall be at

*1

Page 9 of 19

13. MISCELLANEOUS

13.1 Nothing under this Agreement shall be construed as establishing or creating

between the Parties any relationship of Master and Servant or Principal and

Agent between the ESIC and the Blood Bank'

13.2 The Blood Bank shall not represent or hold itself out as agent of the ESIC

13.3 The ESIC will not be responsible in any way for any negligence or misconduct

of the Blood Bank and its employees for any accident injury or damage

sustained or suffered by any ESI beneficiary or any third party resulting from

or by any operation conducted by and on behalf of the Blood Bank or in the

course of doing its work or perform their duties under this Agreement or

otherwise.

13.4 The Blood Bank shall notifu the Government of any material change in their

status and their shareholdings or that of any Guarantor of the Blood Bank in

particular where such change would have an impact on the performance of

obligation under this Agreement,

13.5 This Agreement can be modified or altered only on written agreement signed

by both the parties.

13.6 Should the Blood Bank get wound up or is, the ESIC shall have the right to

terminate the Agreement, the termination of Agreement shall not relieve the

Blood Bank or their heirs and legal representatives from the liability in respect

of the services provided by the Blood Bank during the period when the

Agreement was in force.

13.7 The Blood Bank shall bear-all expenses incidental to the preparation and

stamping of this agreement,

{r

Page 10 of 19

14. NOTICES

l4.l Any notice given by one party to the other pursuant to this agreementshall be sent to other party in writing by registered post or by facsimile andconfirmed by original copy by post to the other party's address as below.

ESIC: Medical Superintendent ESIC Model Hospital, Andheri camped at ESI HospitalKandivali (East) 2nd Floor, Akurli Road.

Blood Bank:

A notice shall be effective when served or on the notice's effective date, whichever islater. Registered communication shall be deemed to have been served even if returnedwith remakes like refused, left, premises locked etc.

lt

Page 11 of 19

(Please read all terms and conditions carefully before filling the application form and

Annexure thereto)

l.Dssurqegli)The EOI document can be download from the website only, website is:

www.esic.nic.in/tenders

2. Document Acceptance:

Duly completed EXPRESSION OF INTEREST forms along with Annexure and necessary

documents may be dropped in person in the EoI Box kept at office of the Dy' M'S' office

Administrate block 2nd floor, ESIS Hospital Kandivali East up to I pm on 30ll1l22l' The

sealed envelope should be super-scribed as "EXPRESSION OF INTEREST for Empanelment of

Blood Bank.

EXPRESSION OF INTEREST received after the

by post) or open EXPRESSION OF INTEREST

prescribed fee shall be summarily rejected'

scheduled date and time (either by hand or

received though e-mail/fax or without the

3. Submission of nxpnnsstox on txtnRnst:

Please ensure that each page of the BxpRESSION OF INTEREST is downloaded and is

submitted in total with each page signed by the proprietor/partner/Director/Legally

Authorized Person (Due autho rrzationto be enclosed, in case of Authorized Person)'

EXpRESSION OF INTEREST will be out rightly rejected if any technical condition is not

fulfil1ed.

Attested photocopy of necessary certificates (as per Annexure-Il) should be attached

with

the EXPRESSION OF INTEREST.

1.

2.

J.

Page 12 of 19

ANNEXTURE.I

Part -A

Rates for Whole Blood/ Blood ComponentsRates for whole Blood and Blood components shall be allowed atfollowing CGHS rates.

These rates are inclusive of cross matching, Blood grouping andothers processing charges.

Sr. No. Elood Components Rates Per Unit (Rs.)I Whole Blood 1450t-2 Packed Red Cell t4s0t -aJ Fresh Frozen Plasma 400t-4 Platelet Concentrate (RDP) 400t-5 Platelet Concentrate - Apheresis Maximum 11000/-

lr

Page 13 of 19

ANNEXURE - II

l. FDA approved.

2. SBTC approved.

3. Supply of blood at CGHS rate.

4. Bio Medical License.

5. Pollution Control Board License.

6. Storage facility.7. Component facilitY - Yes / No.

8. Reservation of blood should be done for at least 48 hrs.

9. Cold chain maintenance.

10.Open on all daYs 24*7.

r.

*1

Page 14 of 19

FORM FOR EOI ANNEXURE- III

APPLICATION FORM (ON LETTER HEAD OF BLOOD BANK)

(Fo. .-puo.l-ert of Horoituls fo. Blood Bunk S".ri..s)To,

The Medical Superintendent

Employees' State Insurance Corporation,

Andheri east,

MUMBAI.

Sub: EXPRESSION oF INTEREST for Empanelment for BLOOD BANK at ESISKandivali.

Sir,

In reference to your advertisement on the website dated, I/ We wish tooffer BLOOD BANK services for nsl Beneficiaries on cashless basis.

I / We pledge to abide by the terms and conditions as mentioned in advertisementand I /We also certify that the above information as submitted by me / us inAnnexure I to VI is correct andl lWe fully understand the consequences of defaulton our part, if any.

Qllame & Signature of the Proprietor/Partner/

Director lLegally authorized signatory)

Place:

Date:

Enclosures: Duly filled Annexures"

io

Page 15 of 19

ANNEXURE _ IVInformation about the Blood Bank / Centre

(EOI / Apnlication form)

(To be submitted duly fitled along with supporting documents along with the

application form for Blood Bank Services.)

1.Name of the Blood Bank

2. Registered Address of theBlood Bank

3. Contact Number

4. Email ID

5. Clinic Registration of the Blood BanldCentre

Name ofIssuing Body

Regi. No. Valid up to

6. Biomedical Waste Management Name ofIssuing Body

Beds Per Reg.Certificate

Valid Up to

7. FDA Approval Certificate

8. SBTC Approval Certificate

9. Type of Firm (Tick whereverapplicable& attach documentary proof)

Public Ltd /Private Ltd/ Prop./Partnership/ Society /Other

10. PAN number of the Firm / BloodBank / Owner.

1L TAN / GST number (Attach self-attested copy)

Page 15 of 19

12. Key Person Details (Owner /Proprietor / Director

Name & Designation Contact Number

13. Details of Authorized Person / Nodal officer (attach authority letter)

Name & Designation Email Id Contact Number

14, Name of existingorganization with whom theHospital is empaneled(Attached relevant validdocuments) I

15. If approved with CGHS/ State Govt / Central Govt /PSU (attached relevant validdocuments) (if applicable)

16. Bank Details (attachcancelled cheque)

Name of Bank

Name of Account Holder

Account Number & IFSC

17. Registration under ESICact (if applicable)

ESI Registration No.

Date:

Place:

(Name & Signature of Proprietor/ Partner / DirectorAuthorized person with office seal / rubber stamp)

Note l. Enclosures should be attached in the order as per the information given below.Note 2. Technical evaluation of the Blood Bank centers shall be based on information provided bythem on the above-mentioned points and they shall mandatory provide documentary pioof for thesame. No future correspondence shall be entertained in this regard

Page 17 of 19

ANNEXURE- V

IINDERTAKING

I/We (name of proprietor/ Ownerl Legally

authorized signatory) have carefully gone through and understood the contents of the

Document form and I / We undertake to abide myself / ourselves by all the terms and

conditions set forth. I / We are legally bound to provide services to ESIC Beneficiaries

as per rates / terms and conditions of EOI documents failing which Medical

Superintendent ESIC Andheri East is liable to take action as deemed fit. I / We

undertake to provide unintemrpted services or alternative arrangement will be made at

the risk of our institute.

I / We have gone through the CGHS rates, terms and conditions available on

CGHS website and ESIC rates.

I / We undertake that the information submitted along with document and

ANNE1URE I & II is correct and also fully understand that in case of default security money

will be forfeited.

I / We certif,/ herewith that my/ our empaneled / Blood Bank has never been

de-empaneled/ black listed by ESIC / CGHS or any other Govt. Institution / PSUs in

the last three years.

Dated:

Place:

Signature

(With seal / rubberstamp)

Name:

i1

Page 18 of 19

ANNEXURE - VI

To

The Medical Superintendent

ESI Corporation HosPital

Andheri East (Based at 2nd Floor, ESIS Kandivali

East) MUMBAI-4000093.

WHEREAS .(Name and Address of Blood Bank)

Agreement

dated....... Valid from..........to .. (Description of Services) her'einafter called

"the Agreement".

AND WHEREAS it has been stipulated by you in the said Agreement that the Blood Bank selected for

empanelment shall furnish you with a bank Guarantee by a nationalized bank for the sum specified

therein as security for compliance with the Blood Bank performance obligations in accordance with the

Agreement. AND WHEREAS we have agreed to give the Blood Bank a guarantee:

THEREFORE WE (Name of the Bank) hereby affirm that we are Guarantors and responsible to you,

on behalf of Hospital (herein after referred to "the Second Party" up to a total of

Amount of the guarantee in Words and Figures) and we

hereby inevocably, unconditionally and absolutely undertake to immediately pay you, upon your first

written demand declaring the Second Party to be in default under the Agreement and without cavil or

argument,anySumorSumSwithinthelimitofasaforesaid,withoutyourneeding to prove or to show this grounds or reasons for your demand or the sum specified therein' This

guarantee is valid until the 30th of November 2023.

This Guarantee shall be incorporated in accordance with the laws of India'

We represent that this Bank Guarantee has been established in such form and such content that is fully

enforceable in accordance with its terms as against the Guarantor Bank in the manner provided herein'

The Guarantee shall not be affected in any manner by reason of merger, amalgamation, restructuring or

any other change in the constitution of the Guarantor Bank or of the Hospital'

Date

Address:

Signature and Seal of Guarantors

has

undertaken,

Page 19 of 19