Current Efforts

Request for Proposals from non-profit and community-based organizations to perform Census 2000 outreach in San Francisco"s historically undercounted populations

 

  1. BACKGROUND:

    The purpose of the San Francisco Complete Count Committee ("CCC") is to assist the U.S. Census Bureau in obtaining an accurate count of the population of the City and County of San Francisco (the "City") for the 2000 Census. The census results are directly linked to funding programs that the City administers, including social, educational, health services, transportation services and law enforcement. In the 1990 Census, there was an estimated undercount of 25,000 persons in the City. This undercount resulted in program funding revenue losses to San Francisco in millions of federal and state dollars. The Board of Supervisors and the Mayor established the CCC to ensure that the upcoming Census reflects a complete and accurate counting of persons residing in the City.

    Outreach and promotion of the 2000 Census is a complex task. Each community in San Francisco typically responds to a different method of communication. The CCC believes that it will be most effective in disseminating the "Be Counted" message by focusing on target communities. The CCC is responsible for getting the Census 2000 message out to hard-to-reach communities in San Francisco, particularly African/African-American, Latino/Hispanic, Asian/Pacific Islander, Russian/Eastern European, homeless and Native American. To perform that task, the City will distribute up to $250,000 to non-profit organizations or collaboratives which work directly in the above-listed communities and are capable of increasing the participation of these communities in the 2000 Census.

  1. OVERVIEW:

    The City Administrator is seeking proposals from non-profit and community-based organizations to perform Census 2000 outreach in San Francisco"s historically undercounted populations.

    The Request for Proposal ("RFP") process will select non-profit/community-based organizations ("CBOs") or collaboratives with access to one or more of the identified hard-to-reach communities: African/African-American, Latino/Hispanic, Asian/Pacific Islander, Russian/Eastern European, homeless and Native American. Selected applicants must have a demonstrated capability to deliver the Census 2000 message to these hard-to-reach populations. Selected grantees will assist in disseminating Census 2000 information to its clientele and encourage people to participate in the Census. The successful applicants will also work with the members of the CCC, the local Census offices, the City"s Census 2000 Project staff, city agencies and other CBOs performing Census 2000 outreach.

    Costs incurred by the applicants in responding to this RFP are entirely the responsibility of the applicants and will not be reimbursed.

    The City reserves the right to:

  1. not allocate the full amount of available funding if insufficient qualified proposals are received;
  2. modify applicant goals and targets of outreach, collaboration, and coordination to avoid duplication and/or increase appropriate outreach to historically undercounted populations;
  3. Reject any and all proposals.
  1. FUNDING PERIOD:

    Grants will be awarded from January 2000 through June 2000.

  2. FUNDING AMOUNTS:

    The total funding for the outreach project is $250,000. Large grants, not to exceed $50,000 or mini grants not to exceed $10,000, will be awarded to individual non-profit organizations, coalitions or collaboratives proposing to perform focused projects.

  1. SERVICES TO BE PERFORMED BY APPLICANT

    Selected applicants will be required to conduct Census 2000 outreach in at least one of the following population groups:

  • African/African-American
  • Russian/Eastern European immigrant
  • Latino/Hispanic
  • Asian/Pacific Islander
  • Homeless
  • Native American

Outreach may include, but is not limited to: distribution of Census 2000 flyers and other promotional materials in a community"s native language; conducting Census 2000 educational forums and/or community events; ethnic media advertising; door-to-door canvassing with Census 2000 information and assistance in filling out census forms.

Outreach efforts should also be designed to motivate the community and encourage everyone who receives a census form in the mail to complete it and mail it back promptly. The applicants should also remind those who did not mail back their forms to cooperate with census enumerators during follow-up to non-responses.

Outreach activities will take place from the time funds are distributed (sometime in early January 2000) through June 2000.

  1. MINIMUM CRITERIA

All applicants must meet the following criteria and provide proof of the following:

  • An organization must be a private non-profit entity with tax-exempt status under section 501(c)(3) of the Internal Revenue Service "(IRS)" rules and regulations or be able to designate a qualified 501(c)(3) that can act as the agency"s fiscal agent.
  • An organization must be in operation for a minimum of two (2) years or be able to designate a qualified 501(c)(3) who can act as the agency"s fiscal agent.
  • An organization must have demonstrated experience or a successful history working with target population(s) and/or residents of the hard-to-reach communities.
  • The proposed project must specifically benefit residents in the City and County of San Francisco.
  • Attach a resume of work experience documentation
  • An application must be complete and received by the deadline.
  • An organization must submit the most recent independent financial audit, including the management letter if one has not been issued in conjunction with the audit report.

For those applicants applying as a collaborative* or coalition** the following criteria must be met:

  1. For a collaborative, there must be one lead agency that meets all of the above requirements and is further responsible for leadership, accountable for the collaborative meeting its identified goals, able to provide oversight/monitoring of partners and serves as the liaison to the City and County of San Francisco. When applying as a collaborative, the applicant must clearly identify roles and responsibilities of each collaborative partner and dedicated staff.
  2. For a coalition, the organization must coordinate, convene, and reach out to one or more of the following six broad ethnic-based populations. When applying to coordinate a coalition, the applicant must clearly identify the specific steps necessary to reach undercounted populations.
  • African/African-American
  • Russian/Eastern European immigrant
  • Latino/Hispanic
  • Asian/Pacific Islander
  • Homeless
  • Native American

* A Collaborative is defined here as two or more non-profit organizations applying together for one funding allocation.

** A Coalition is defined as an organization acting as a coordinator of at least three non-profit agencies performing Census 2000 outreach in one or more of the following six ethnic populations in the City and County of San Francisco:

  • African/African-American
  • Russian/Eastern European immigrant
  • Latino/Hispanic
  • Asian/Pacific Islander
  • Homeless
  • Native American
  1. PRIORITY:

 

Priority will be given to proposals that are able to demonstrate the following:

  • Access to one or more of the identified hard-to-reach communities with which applicant has a level of established trust and a history of positive experience
  • Access to residents of specific census tracts that historically have had a low response rate to the census survey.
  • Collaboration with other organizations and/or may leverage the funding/outreach efforts with additional funds or volunteers
  • Provide direct contact with the target populations
  1. Clearly defined goals and measurable outcomes within realistic, achievable time frames.
  1. SUBMISSION OF RFP RESPONSES

 

    1. Tentative Calendar of Events
    ACTION DATE*

    Funding Period

    January 2000 - June 2000

    Contact Staff

    Dang Pham, City Census 2000 Liaison
    City Hall - Room 362
    One Dr. Carlton Goodlett Place
    San Francisco, CA 94102
    415-554-7583

    RFP Issue Date

    December 1, 1999

    Pre-proposal/Information Meeting

    December 8, 1999

    Due Date for Proposals

    December 15, 1999

    Address for Mailing or Personal Delivery

    Dang Pham, City Census 2000 Liaison
    City Hall - Room 352
    One Dr. Carlton Goodlett Place
    San Francisco, CA 94102

    Proposal Review

    December 27, 1999 - December 31, 1999

    Notification of Grantees

    January 7, 2000

    Complete Grant Negotiations

    January 14, 2000

    Service Implementation

    January 15, 2000

    * Dates are subject to change

  1. Pre-Proposal/Information Conference

Proposers are encouraged to attend a pre-proposal/information conference on Wednesday, December 8, 1999, at 11:00 A.M. to be held at Conference Room 201 in the City Hall - One Dr. Carlton B. Goodlett Place, San Francisco, CA 94102. All questions will be addressed at this conference and any available new information will be provided at that time. If you have further questions regarding the RFP, please contact Dang Pham at 415-554-7583.

The City will keep a record of all parties who request and receive copies of the RFP. Any requests for information concerning the RFP whether submitted before or after the pre-proposal conference, must be in writing, and any substantive replies will be issued as written addenda to all parties who have requested and received a copy of the RFP from the City Administrator. Questions raised at the pre-proposal conference may be answered orally. If any substantive new information is provided in response to questions raised at the pre-proposal conference, it will also be memorialized in a written addendum to this RFP and will be distributed to all parties that received a copy of the RFP. No questions or requests for interpretation will be accepted after December 10, 1999.

  1. Required Proposal Format and Content

All applicants must submit a written proposal that describes how the provider meets the requirements outlined in this RFP, following the format listed below. All sections indicated below must be clearly identified in the proposal. The narrative of outreach plan is not to exceed 5 numbered pages (excluding the budget page), on 81/2 x 11 size paper. The narrative of outreach plan must be typed, double-spaced, single-sided and consecutively numbered. Use Times New Roman (12 point) font or the equivalent. One original and five (5) complete copies must be submitted.

  1. Cover page and Board Letter of Authorization (Attachment)

    All proposals must be signed by an authorized officer or employee of the agency submitting the proposal.

  2. RFP Checklist (Attachment)
     
  3. Table of Contents
     
  4. Primary Intent

    Describe how services will be delivered to meet the primary intent of the proposal for services

  5. Narrative of Outreach Plan
    Clearly indicate each item in the proposal. This section is not to exceed 5 pages
  1. Services and Activities - Describe the specific services and activities to be conducted in the proposed program to demonstrate how these will achieve the primary intent of the CCC. Also designate one contact person to communicate with the CCC.
     
  2. Target Population - Clearly describe the community that will be served in the proposed program. Describe how the program will serve this population and its proximity and relation to the target community. What are the issues facing this population and what are their critical needs to be addressed.
     
  3. Cultural Competency and Proficiency - Describe how the proposed program will be designed to meet the needs of the target community. Describe how the agency will ensure that elements of culture, such as language, values, and traditions will be incorporated into the services provided. Describe staff skills and language ability that will be required in order to provide culturally specific services and information.
     
  4. Program Collaboration - Describe how the proposed program will collaborate with other non-profit organizations in developing and delivering these services. Describe your agency"s previous experience with collaboration.
     
  5. Timeline - Outline the timeline for proposed project implementation with the outreach activities during the pre and post Census Day of April 1, 2000.
  1. Budget

    Provide the project budget. Include a complete budget narrative explaining program costs, staff time, services and supplies. Also, include other sources of expected funding from public and private entities.

  2. Financial Statement

    Each agency must submit a copy of the most recent and complete audited annual financial statement (within past 12 months).

  3. Organizational Capability - Each applicant must submit the following information
  • Business and official mailing address of the agency, telephone and fax numbers
  • Description of the organization
  • Legal business status
  • Number of years the agency has been in business under present or prior names
  • Number of years of experience the agency has in working and/or performing outreach in defined target community
  • Listing of board members
  • Description of experience and qualifications of members of the proposed project team
  • Relevant experience
  • Proof of 501(c)(3)status
  • Articles of Incorporation
  • By-laws
  • Provide the Certificate of the Federal Taxpayer Identification Number (FEIN)
  1. Other Requirements
    1. Proof of insurance and liability limits that meet the City and County of San Francisco insurance requirements.
    2. Complete reference information from a minimum of three (3) institutions or agencies other than the City & County of San Francisco for which the applicant provides or has provided comparable services.
  1. Submittal of Proposals

Qualified agencies may submit proposals for the program. The program proposal will be evaluated and scored. Failure to submit a complete proposal for the program will disqualify the applicant from consideration.

  1. Submit one original and five (5) complete copies of the proposal in a sealed envelope to:

    Dang T. Pham
    City Census 2000 Liaison
    City and County of San Francisco
    City Hall - Room 352
    One Dr. Carlton Goodlett Place
    San Francisco, CA 94102

  2. Proposals submitted by fax will not be accepted.
     
  3. Proposals will be accepted until 5:00 p.m. on December 15, 1999.

    Proposals delivered after this date and time will not be accepted. Postmarks will not be accepted in lieu of actual receipt.

  4. No adjustments to the proposal package will be accepted after the acceptance deadline.
     
  5. Proposals become the property of the City and County of San Francisco and shall not be returned.

     

IX. EVALUATION CRITERIA

To determine that all conditions of the RFP have been met, the City"s Evaluation Committee will conduct technical review of all proposals. Proposals must follow the format detailed in Section VIII (B), and applicants must submit all required information and documents. A proposal will be rejected if any section is omitted, is incomplete or fails to meet any conditions of the RFP.

The City and County of San Francisco reserves the right to reject any and all proposals. The right to accept a proposal, in whole or in part, is also reserved. Changes in the proposal may be proposed by the Evaluation Committee and negotiated with the contract award recipient.

The evaluation of the proposals is based on the point system, which will total 100 points. The total points allocated to each proposal will serve as a guide for the selection of the contract awardees.

  1. TERMS AND CONDITIONS:
  1. Subcontracting of outreach activities is prohibited, however, collaboration and cooperative activities between CBOs are encouraged. All cooperative efforts and the partners involved therein shall be detailed in the proposal. Time schedules for events and/or activities must be detailed in the proposals.
     
  2. All proposals will be subject to two performance evaluations with the first occurring between March 1 and March 15, 2000, and the second occurring between April 1, 2000 and April 15, 2000. Performance evaluations will assess the award recipient"s effectiveness through June 2000. This final evaluation must include the expenditure report, the community"s response to the outreach activity and the applicant"s assessment of outreach effectiveness.
     
  3. The award recipient shall identify, in writing, any requested exceptions to all specified terms and conditions.
     
  4. Proposers are responsible for reviewing all portions of this RFP. Proposers must promptly notify the City Administrator in writing, if the proposer discovers any ambiguity, discrepancy, omission, or other error in the RFP. Any such notification should be directed to the City Administrator promptly after discovery, but in no event later than five (5) working days prior to the date for receipt of proposals. Modifications and clarifications will be made by addenda as provided below.
     
  5. The City Administrator may modify the RFP, prior to the proposal due date, by issuing written addenda. Addenda will be sent via regular, first class U.S. mail to the last known business address of each organization listed with the City Administrator"s office as having received a copy of the RFP for proposal purposes. The City Administrator will make reasonable efforts to notify in a timely manner of modifications to the RFP. Notwithstanding this provision, the proposer shall be responsible for ensuring that its proposal reflects any and all addenda issued by the City Administrator prior to the proposal due date regardless of when the proposal is submitted. Therefore, the City recommends that the proposer call the City Administrator"s office before submitting its proposal to determine if the proposer has received all addenda.
     
  6. A proposer may revise a proposal on the proposer"s own initiative at any time before the deadline for submission of proposals. The proposer must submit the revised proposal in the same manner as the original. A revised proposal must be received on or before the proposal due date.

    In no case will a statement of intent to submit a revised proposal, or commencement of a revision process, extend the proposal due date for any proposer.

    At any time during the proposal evaluation process, the City Administrator may require a proposer to provide oral or written clarification of its proposal. The City reserves the right to make an award without further clarifications of proposal received.
     
  7. Failure by the City Administrator to object to an error, omission, or deviation in the proposal will in no way modify the RFP or excuse the vendor from full compliance with the specifications of the RFP or any contract awarded pursuant to the RFP.
     
  8. The City accepts no financial responsibility for any costs incurred by an organization in responding to this RFP. Submissions of the RFP will become the property of the City and may be used by the City in any way deemed appropriate.
     
  9. In accordance with San Francisco Administrative Code section 67.24 (e), responses to RFP"s and all other records of communications between the City and persons or organizations seeking grants shall be open to inspection immediately after a grant has been awarded. Nothing in this division requires the disclosure of a private person"s or organization"s net worth or other proprietary financial data submitted for qualification for a grant or other benefits until and unless that person or organization is awarded the grant or benefit. Information provided which is covered by this paragraph will be made available to the public upon request.
     
  10. If a proposer is a non-profit entity that receives a cumulative total per year of at least $250,000 in City-funds or City-administered funds and is a non-profit organization as defined in Chapter 12L of the San Francisco Administrative Code, the Proposer must comply with the reporting requirements of that Chapter. The Proposer must include in its Proposal (1) a statement describing its efforts to comply with the Chapter 12L provisions regarding public access to Proposer"s meetings and records, and (2) a summary of all complaints concerning the Proposer"s compliance with Chapter 12L that were filed with the City in the last two years and deemed by the City to be substantiated. The summary shall also describe the disposition of each complaint. If no such complaints were filed, the Proposer shall include a statement to that effect. Failure to comply with the reporting requirements of Chapter 12L or material misrepresentation in Proposer"s Chapter 12L submissions shall be grounds for rejection of the Proposal and/or termination of any subsequent Agreement reached on the basis of the Proposal.
     
  11. The issuance of this RFP does not constitute an agreement by the City that any grant will actually be entered into by the City. The City expressly reserves the right at any time to:
    1. Waive or correct any defect or informality in any response, proposal, or proposal procedure;
    2. Reject any or all proposals;
    3. Reissue a Request for Proposals;
    4. Prior to submission deadline for proposals, modify all or any portion of the selection procedures, including the deadlines for accepting responses, the specifications or requirements for any materials, equipment or services to be provided under this RFP, or the requirements for contents or format of the proposals;
    5. Procure any materials, equipment or services specified in this RFP by any other means; or
    6. Determine that no project will be pursued.
       
  1. No waiver by the City of any provisions of this RFP shall be implied from any failure by the City to recognize or take action on account of any failure by a Proposer to observe any provision of this RFP.
  1. GRANT REQUIREMENTS
  1. Chapter 12B and 12C: Nondiscrimination in Employment and Benefits

Chapter 12B and 12C of the San Francisco Administrative Code are incorporated by reference as though fully set forth herein. Chapter 12B and 12C prohibit discrimination by City grantees in employment, the use of property, the provision of public accommodations and in the provision of benefits to employees with domestic partners and employees with spouses, and/or between the domestic partners and spouses of such employees.

The successful Proposer must agree to abide the following standard grant provisions regarding Chapter 12B and 12C:

(a) Grantee Shall Not Discriminate. In the performance of this agreement, the grantee agrees not to discriminate on the basis of the fact or perception of a person"s race, color, creed, religion, national origin, ancestry, age, sex, sexual orientation, gender identity, domestic partner status, marital status, disability, or Acquired Immune Deficiency Syndrome or HIV status (AIDS/HIV) against any employee of, any City employee working with, or applicant for employment with grantee, in any of grantee"s operations within the United States, or against any person seeking accommodations, advantages, facilities, privileges, services, or membership in all business, social, or other establishments or organizations operated by grantee.

(b) Nondiscrimination in Benefits. Grantee does not as of the date of this Agreement and will not during the term of this Agreement, in any of its operations in San Francisco, on real property owned by San Francisco, or where work is being performed for the City elsewhere in the United States, discriminate in the provision of benefits between employees with domestic partners and employees with spouses, and/or between the domestic partners and spouses of such employees, where the domestic partnership has been registered with a government entity pursuant to state or local law authorizing such registration, subject to the conditions set forth in Section 12B.2(b) of the San Francisco Administrative Code.

(c) Condition to Grant. As a condition to this Agreement, Grantee shall execute the "Nondiscrimination in Grants and Benefits" form and secure the approval of the form by the San Francisco Human Rights Commission.

(d) Incorporation of Administrative Code Provisions by Reference. The provisions of Chapter 12B and 12C of the San Francisco Administrative Code are incorporated by reference and made a part of this Agreement as though fully set forth herein. Grantee shall comply fully with and be bound by all of the provisions that apply to this Agreement under Chapter 12B and 12C of the Administrative Code, including but not limited to the remedies provided in such Chapters. Without limiting the foregoing, Grantee understands that pursuant to Section 12B.2(h) of the San Francisco Administrative Code, a penalty of $50 for each person for each calendar day during which such person was discriminated against in violation of the provisions of this Agreement may be assessed against Grantee and/or deducted from any payments due Grantee.

 

B. Year 2000 Readiness Status

In the event that is necessary for the Grantee to supply and install equipment that is in any way computerized, prior to installing the equipment the Grantee must submit a narrative statement ensuring that any equipment provided by the Grantee is Year 2000 compliant. Information that the Grantee will be required to provide may include the following:

  1. Whether inventorying and testing of software, hardware, and equipment has been completed, and if not, when completion is anticipated;
  2. What steps have been and will be taken to ensure that no disruption of service will occur as a result of Year 2000-related problems;
  3. Grantee"s anticipated completion date for Year 2000 compliance; and
  4. Whether Grantee has a contingency plan for continuing operations in the event of any Year 2000-related failure.

C. Standard Grant Provisions

The successful Proposer will be required to enter into a grant substantially in the form of the Grant Agreement, attached hereto as Appendix A. Failure to timely excute the Agreement, or to furnish any and all certificates, bonds or other materials required in the Agreement, shall be deemed an abandonment of a grant offer. The City, in its sole discretion, may select another agency or organization and may proceed against the original selectee for damages.

In addition, the successful Proposer will be required to execute the following City forms:

 

  1. Chapter 12B Declaration. The successful Proposer must submit the "Chapter 12B: Nondiscrimination in Grants and Benefits" form (form HRC-12-101) contained in Appendix B and have the form approved by HRC prior to being awarded the grant. Two other forms are included in the Appendix B: "Reasonable Measures Affidavit" (form HRC-12B-102); and "Substantial Compliance Authorization Form" (form HRC-12B-103). Proposers should execute and submit these forms if, in accordance with the forms" instructions, it is appropriate to do so.
     
  2. Tropical Hardwoods/Virgin Redwood Ban. Any proposal submitted in response to this Request for Proposals which calls for the use of any tropical hardwood or tropical hardwood product, virgin redwood or virgin redwood product, as defined in San Francisco Administrative Code Chapter 12L, shall be deemed non-responsive.

 

EVALUATION INFORMATION

 

A. Description of Agency or Organization
5 points
This should include the types of services provided by the agency or organization and history of community service to the target population.
B. Target Population
25 points
The narrative should include a demographic profile of the target population and the applicant"s experience in serving the target population. Describe what methods will be employed to ensure cultural competence related to the target population.
C. Working with Other Agencies
20 points
The applicant must demonstrate a history of successful collaboration with other agencies.
D. Fiscal and Administrative Capability
5 points
The proposal must demonstrate that the organization has experience and financial viability, liability insurance and the administrative and organizational capability to provide the proposed services. The applicant is capable of providing satisfactory service to the target population.
E. Budget
5 points
The applicant must submit a complete and fully documented budget.
F. Outreach Plan
40 points
The proposed outreach plan must address all issues outlined in the RFP. Each item will receive a maximum of 8 points.

 

CENSUS 2000 PROJECT
REQUEST FOR PROPOSAL
CHECKLIST

Use the following checklist to assure that all papers and forms necessary to respond to this RFP have been included. Submit a copy of this checklist as the second page of your application as indicated in the required format. Submit one (1) original and five (5) copies. All documents, unless otherwise specified, are required for a proposal to be considered complete. Incomplete proposals will not be accepted.

 COVER PAGE & BOARD LETTER OF AUTHORIZATION

 RFP CHECKLIST (This Page)

 TABLE OF CONTENTS

 PRIMARY INTENT - NARRATIVE

 NARRATIVE SERVICE PLAN

 Services and Activities

 BUDGET

 FINANCIAL STATEMENT

 ORGANIZATIONAL CAPABILITY

 OTHER REQUIREMENTS

 Proof of Insurance (form ACORD 25-S (1/95))

 Three (3) references.


 

CENSUS 2000 PROJECT
REQUEST FOR PROPOSAL
COVER PAGE AND BOARD LETTER OF AUTHORIZATION

PROGRAM: _____________________________________________________________

LEGAL AGENCY NAME: __________________________________________________

ENTITY: _________________________________________________________________

OTHER NAMES: __________________________________________________________

BUSINESS ADDRESS: ____________________________________________________

CITY ___________________________ CA ________________

CHIEF ADMINISTRATOR: _________________________________________________

CONTACT PERSON: ______________________________________________________

TELEPHONE NUMBER: ___________________________________________________


PROSPECTIVE CONTRACTOR AGREES:

  1. To comply with the specifications and terms for the provisions of the Census 2000 Outreach Program as contained in the Request for Proposal and any resulting contract.
     
  2. To be bound by the responses to this proposal if awarded the contract.
     
  3. To provide the City and County of San Francisco with any other information necessary for an accurate determination of the prospective contractor"s qualifications.
     
  4. That the City and County of San Francisco shall have the right to conduct an audit of financial records for the purpose of determining the prospective contractor"s financial condition.
     
  5. That this certifies that all statements in the proposal package itself are true. This shall constitute a warranty, the falsity of which shall permit the City and County of

    San Francisco to pursue any remedy authorized by law, which shall include the right, at the option of the City and County, to declare any contract as a result to be void.

  6. That the proposal is valid and enforceable for up to 180 days from the proposal opening date.
     
  7. That funding for any resulting contract is contingent upon the availability of the City and County"s Census 2000 Project funds.
     
  8. To comply with the City and County of San Francisco"s insurance provisions, to provide appropriate indemnification for the City and County and to hold the City and County harmless from contractor"s performance of the contract.

SIGNATURE OF AUTHORIZED REPRESENTATIVE

NAME: _________________________________________________________________

TITLE: __________________________________________________________________

DATE: __________________________________________________________________

TELEPHONE: ____________________________________________________________