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Lock Out Tag Out (LOTO) Safety Procedure-
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Table of Contents
1. INTRODUCTION....................................................... 3
2. PURPOSE.................................................................... 3
3. SCOPE.......................................................................... 3
4. RESPONSIBILITIES................................................. 3
5. PROCEDURE.............................................................. 5
5.1 GENERAL............................................................... 5
5.2 REQUIREMENTS FOR
ISOLATION OF MACHINERY/EQUIPMENT.................................... 6
5.3 SWI FOR THE ISOLATION
OF MACHINERY/EQUIPMENT.................................... 7
5.4 SUPPLIERS, DESIGNERS, MANUFACTURERS... 7
5.5 ISOLATION OF MACHINERY/EQUIPMENT... 7
5.6 ISOLATION OF
MACHINERY/EQUIPMENT.......... 8
6. TRAINING and RETRAINING................................ 9
7. DEFINITIONS.......................................................... 10
8. REFERENCES........................................................
1.
INTRODUCTION
Pars Oil and Gas Company (POGC), a subsidiary of
National Iranian Oil Company (NIOC), was established in 1998. POGC is a developmental and manufacturing organization that specializes in the
fields of engineering and management of development projects, production, operation and integrated management of oil and gas reservoirs. POGC’s mission is to ensure sustainable and preservative
production and development of Iran’s
oil and gas industry in the areas under its responsibility, development of oil
and gas value chain as well as
optimization of energy supply processes at national, regional and international levels. POGC is also in
charge of development of joint and non-joint oil and gas fields of the
country including South Pars, North Pars, Golshan and Ferdowsi.
Aimed at creating superior value and boosting the level
of satisfaction of the beneficiaries and with an approach
focusing on sustainable, integrated and knowledge-oriented production and development, the company feels committed to
comply with national and international
requirements, regulations and standards in such areas as quality, safety, as well as
occupational and environmental health.
2.
PURPOSE
This procedure aims to prevent injury or risk of
fatality to all employees and staff caused by
the unexpected energizing, start-up or release of stored energy when working on equipment, machinery or systems.
LOTO system programs
to use energy isolating devices to disable machines or equipments
to prevent unexpected start up or release of
stored energy that may cause injuries.
3.
SCOPE
This procedure covers
the servicing and maintenance of machines and equipment in which
the unexpected energizing or start-up of the machines or equipment, or release
of stored energy, could cause injury to employees and safety statement
to protect all employees
in South Pars field from the hazards of energy sources by the safe method of locking
and tagging of isolated devices..
This document establishes minimum performance requirements for the control of such hazardous energy for protection
4.
RESPOSIBILITIES
4.1 Commissioning Manager/Shift
SI
·
Ensuring that all persons working are aware of, and comply with the relevant points
from this Safety Procedure.
4.2 Field Supervisor
The Field Supervisor is responsible for:
· Ensuring that all
procedures and safeguards are
fully implemented.
· Preparation of
the work-site to ensure that
activities will be conducted safely.
·
Monitoring the PTW of the significant activity and supervision of lock out tag out system after a safe isolation.
Safety supervisor / Safety Engineer
The Safety
supervisor /Safety Engineer are responsible for:
· Monitoring the
safety of all working practices all
over the gas plant.
· Ensuring about safety performance of LOTO according to this procedure.
·
Close cooperation and coordination with substation operators
and field operators
due to LOTO system.
Substation operator
·
Substation operator
must be fully trained and aware of LOTO system.
·
He must have a good cooperation
with Safety supervisor and field operator and to perform LOTO system within electrically isolated devices according
to this procedure.
Head of Maintenance
·
Head of maintenance must have a
supreme control on the performing LOTO system
during any maintenance activity, he must also be sure that all his
employees and subcontractors have
been trained properly about LOTO system according to this procedure.
Departments & Contractors
·
Main Contractors and subcontractors which are subject
to LOTO system are responsible for establishing and
documenting Lock out Tag Out procedures. Some
available resources to assist departments include: Equipment
manufacturers, their service representatives or; the equipment
operator’s manual, can provide information on how to safely isolate
the equipment’s energy source(s) during service
or maintenance activities. These procedures shall apply to each piece of equipment, machinery or system under the
department’s control that is serviced and maintained by the department’s employees. Procedures may be established for classes of
equipment or machinery if their function and operation are similar and the procedure can collectively account
for the control of all hazardous energy sources.Main Contractors and subcontractors must evaluate and document the effectiveness
of their Lock Out Tag Out system each year and correct any noted deficiencies. The departmental system must meet
the following requirements:
Authorization through
Training and Qualification
–
All persons must be authorized through
training and qualification on the departmental Lock Out procedures for the
equipment and machinery they are assigned to
work on. This training must be completed before they can perform any service or maintenance. Training and qualification
must include understanding safe operation of
the equipment and the use of the Lock Out devices and warning tags
provided by the department.
Lock out
Devices, Individually Keyed Padlocks and Warning Tags
– All
departments must provide appropriate lock out devices, individually keyed padlocks and warning tags to each
Authorized Person. Affected personnel who will be assigned to work on a locked out piece of equipment, machinery
or system including
 |
working in a controlled area, must be provided with his individual padlock and warning tag.
Lockable Energy Isolation Device
– Main
Contractors are responsible for requesting the installation of lockable energy isolation devices onto their equipment or machinery whenever
there is major replacement, repairs,
renovation or modification to the equipment. Generally,
the referenced equipment and machinery
is production equipment
and Facilities equipment (i.e., HVAC, fans,
motors, boilers, etc.).
All equipment and machinery must include
specifications that the energy isolation device(s) are lockable.
5.
PROCDURE
5.1
General :
The unexpected energization, start-up or release
of stored energy during operation, servicing or maintenance work (e.g. inspection, repair,
adjustment, cleaning), on machinery or equipment
can lead to serious worker injuries. To prevent accidental release or transmission of energy, appropriate
procedures must be implemented to
deactivate the specific machine or equipment, to isolate it from its energy source, and to lock and tag out the energy isolating device (e.g. breaker,
switch, valve, blocks,
disconnect switch).
“Lockout” is the placement
of a locking device on an
energy isolation device (circuit breaker, slide gate, line valve, switch,
etc.) to insure the energy isolating device and equipment being controlled, cannot be
operated until the lockout device is removed. A lockout device utilizes a positive means such as a lock (key or
combination type) to hold an energy
isolating device in a safe position and prevent the energization of a machine
or equipment. The lockout device must
be substantial enough to prevent removal without use of excessive force or unusual techniques.
“Tag out” is the placement
of a tag out device (a tag or other prominent warning device and a
means of attachment) on an energy isolation device to indicate the energy
isolating device and equipment being controlled may not be operated until the tag out device is removed.
The lockout device must be used unless the employer can demonstrate that the utilization of a tag out system
will provide full employee protection. The tag out device must be non- reusable and attached by hand. The tag out
program must provide a level of safety equivalent to a lockout
program.
Supervisors must conduct an assessment of the machine or
equipment and all associated energy sources
(i.e. electrical, mechanical,
hydraulic, pneumatic, chemical, thermal, or other) in order
to determine the appropriate lockout/tagout procedures.
Requirements for Lockout/Tagout Procedures
Written lockout/tagout procedures specific to a particular machine
or equipment, or to a similar grouping
of machines or equipment, must outline the situations in which they are to be used,
and the sequence in which they are to be used.
Lockout/tagout procedures shall clearly define
the specific actions
and responsibilities required during each of the following energy
control sequences:
1)
Preparation for shutdown
2) Equipment shutdown
 |
3) Equipment isolation from the energy
source
4) Application of lockout/tagout devices
5) Release of stored energy,
de-energization
6) Verification of isolation
7)
Release from lockout/tagout control
once work is completed, including removal of lockout/tagout devices and restoration of energy to machinery/equipment.
Lockout and Tagout Devices
A combination
of a
lockout device and a tagout
device shall be used for all lockable energy isolating devices.
The lockout device (e.g. padlock)
physically prevents the energizing
of the machine or equipment. The tagout device (tag, sign) provides information about
the nature of the lockout
and warns workers
to not operate the particular machine/equipment/device. A tagout device is also used when an
energy isolating device is not lockable,
along with additional protective measures to ensure maximum
worker protection.
Each worker involved
in service or maintenance work must apply his/her own assigned personal
lock, and carry his/her own key. Combination type locks or locks with master or duplicate keys must not be used.
Lockout and tag out devices must be:
• durable for the environment in which they will be used;
• sturdy enough to minimize
early or accidental removal;
• unique, distinctive, easily recognizable and clearly visible;
• standardized as to color,
shape, size, type or format;
and
• identifiable as to the worker(s) authorizing or applying them.
This procedure is essentials to all employees subject to any
isolation of energy sources and LOTO
system to fully study and understand it and follow it within all activities
such as working on pipelines, confined spaces, electrical
devices or any other energized devices.
5.2
REQUIREMENTS FOR ISOLATION OF MACHINERY/EQUIPMENT
•
Where energy sources are present,
instructions for the isolation and re- activation of machinery/equipment need to be developed for each piece of machinery/equipment as part of their safe work instructions (SWI).
•
The detail of the instructions will
depend upon the identification and assessment of the hazards through
the risk assessment process and
consequential risks involved
with each piece
of machinery/equipment.
•
It is essential that managers
and supervisors carry
out this assessment and put into place
control measures including
machinery/equipment isolation instructions before the machinery/equipment becomes operational.
•
Isolation points, which can be locked
or tagged out, should
be provided along the route of each potential energy source where practicable.
 |
5.3
SWI FOR THE ISOLATION
OF MACHINERY/EQUIPMENT
SWI for isolation of machinery/equipment must include:
• the situation under which the isolation procedure
is to be implemented;
• the means and sequence by which the isolation will be achieved;
• the checks
that are to be performed prior to the
commencement of work;
•
name/position of persons authorised
to perform checks or issue permits (if required) related to isolation for the work location and the work to be
done; and
•
any other special requirements for
the isolation of machinery/equipment or re-
energization.
5.4 INFORMATION FROM SUPPLIERS,
DESIGNERS, MANUFACTURERS AND IMPORTERS OF MACHINERY/EQUIPMENT
Suppliers, designers, manufacturers and importers of the machinery/equipment have a legal obligation to supply sufficient information to enable the safe operation and maintenance of the machinery/equipment including isolation and the
risks
associated with the machinery/equipment during
repair, service or maintenance.
5.5 ISOLATION OF MACHINERY/EQUIPMENT
5.5.1 Using the hierarchy
of control
•
When isolating or
removing machinery/equipment from service, it is
important to consider the hierarchy
of controls in the type of isolation used.
•
Engineering controls must be used in preference to administrative
controls due to their increased
effectiveness.
•
An isolation tag gives the least
protection whilst isolation using a locking device and removal from service through physical relocation or the
use of barricades where practicable provide a higher
level of protection to the users of the area and maintenance personnel.
5.5.2
Portable machinery/equipment
•
Turning off the power supply and removing the plug from the supply socket (if safe to do so) can normally
isolate simple portable
type machinery/equipment.
• A tag or physical restraint device can then be applied
as per this procedure
5.5.3
Multiple parties working on machinery/equipment
•
Typically the repair, service
or maintenance work on a piece of machinery/equipment may involve different
groups, service providers
or organisations.
•
The group that is responsible for the day-to-day operations of that machinery/equipment has the primary
responsibility for the safety and safe operation
of the machinery/equipment.
|
•
If the repair, service or
maintenance work is undertaken by another group or contractor, the laboratory/studio/workshop supervisor or
responsible officer must ensure
that appropriate isolation procedures are being followed and that the other group
or contractor is competent in the work they are expected to carry out.
•
For work involving a second party,
a two-tag isolation
system must be used.
This involves the use of
tags or locking devices for the work location and a separate tag or locking device for the group
undertaking the work. In this case both parties must remove their own tags
or locks on completion of the work.
5.5.4
Removal of isolation tags or devices
•
Accidental removal of the isolation tag or
device must be rectified immediately. This requires placing
an isolation tag or device of your own on the machinery/equipment and the immediate
notification of the removed isolation tag directly or to the laboratory/studio/workshop
supervisor or responsible officer.
•
The incident must be reported through
HSE MANAGER and Incident Reporting procedure.
•
Isolation tags and devices
are not to be used for any other purpose other than those directed
in this procedure.
5.6
PROCEDURES FOR THE ISOLATION OF MACHINERY/EQUIPMENT
5.6.1
If
safe to do so, stop machinery/equipment and isolate each energy source
according to SWI or isolation documentation for the machinery/equipment.
5.6.2
A
yellow & black, 'Caution', isolation
tag must be completed, signed and secured
to each isolation device at a prominent
position. The laboratory/studio/workshop supervisor or
responsible officer must be notified of the machinery/equipment failure and isolation.
5.6.3
The laboratory/studio/workshop supervisor or responsible officer must check that
machinery/equipment is isolated
effectively and is de-energised for safe repair, service or maintenance work. Isolation locally, at points along the energy route, as
well as at the energy
source where practicable, is preferred.
5.6.5
The laboratory/studio/workshop supervisor or responsible officer
may remove original
tag and re-tag out machinery/equipment with his or her own completed and signed
'Caution' tag, if required.
•
Any further isolation such as locking devices
or removal from service should
also take place
at this time.
•
It is good practice to communicate to relevant personnel that the machinery/equipment is out of service and why.
•
The 'Caution' tag must remain on the machinery/equipment until machinery/equipment is fully repaired
and ready to be re-energized.
5.6.6
Machinery/equipment may then undergo
repair, service or maintenance work by
competent service providers or authorised personnel.
•
These personnel must securely
apply a completed
and signed white & red 'Danger'
tag and isolation device to each isolated energy source.
•
Each member of the service provider
must check the isolation of the machinery/equipment and use individual
tags and isolation devices on each of the isolation points along the route of the energy
source.
•
A 'Danger' tag may only be removed by the person who applied and
signed the tag, unless in an emergency.
5.6.7
Until all tags are removed, the
machinery/equipment must remain out of service. Once removed, any tags must be destroyed
and not reused.
5.6.8
Re-energising of the machinery/equipment or section must be performed
according to the reactivation procedure of the machinery/equipment or
under the supervision of the laboratory/studio/workshop supervisor or responsible officer,
ensuring all energy sources
are clear, safe to activate and that protective guarding or interlocks are operational.
6.
TRAINING and RETRAINING
All employees subject to LOTO system shall be trained so
that they understand the purpose and
function of the LOTO system and procedures.
Training must include recognition of warning tags, lock
out devices, and that tags and locks can only be removed by the Authorized Person who took the equipment
or machine out of operation.
Training shall include
the following:
·
Each authorized employee shall
receive training in the recognition of applicable hazardous energy sources, the type and magnitude of the energy
available in the workplace, and the
methods and means necessary
for energy isolation and control.
·
Each affected employee shall be
instructed in the purpose and use of the energy control procedure.
·
Training Centre shall conduct
hazardous energy control training for all authorized employees.
·
All other employees whose work
operations are or may be in an area where energy control procedures may be utilized,
shall be instructed about the procedure, and about the prohibition relating
to attempts to restart or reenergize machines
or equipment which are locked out or tagged out.
· Supervisors shall receive training on there
supervisory responsibilities.
Retraining
shall include the following:
·
whenever there is a change in job
assignment, machines, equipment or processes that present a new hazard or a change in the energy control procedures.
·
Retraining shall be provided for
all authorized and affected employees whenever
there is a change in their job assignments, a change in machines,
equipment or process that present a
new hazard, or when there is a change in the energy control procedures.
·
Additional retraining shall also be
conducted whenever a periodic inspection reveals, or there is reason to believe that there are deviations from
or inadequacies in the employees’ knowledge or use of the energy control
procedure
·
The retraining shall reestablish
employee proficiency and introduce new or revised control methods and
procedures as necessary.
·
The trainer shall certify that
employee training has been accomplished and is being kept up to date. The certification shall contain each
employee’s name and dates of training
Record Keeping
Main Contractor training
centre will maintain
training records, including each employee's name and dates of training.
Main Contractor HSE Department will retain records
of the annual Lockout / Tag out system audit.
7.
DEFINITIONS :
Affected Person(s): Affected person is any employee who has been designated by his department to operate equipments,
machineries or systems that can be affected during the shutdowns for service and/or maintenance. Shutdowns are
performed by Authorized Persons using
Lock Out procedures. In addition, personnel may be affected by shutdowns and
Lock Out procedures when they are
working in controlled spaces (e.g., electrical power to work area is secured
during renovation, demolition activities
or abatement of hazardous
materials).
Authorized
Person(s): Authorized Person is any employee who
has been designated by his department
to perform maintenance or service on a piece(s) of equipment, machinery or
system and is qualified to perform the work through
proper training on the Lock out Tag Out procedures for the equipment, machinery or system.
Cord and Plug-connected
Equipment: Equipment that is powered by an electrical energy source
that can be shut down by removing the cord and plug from the energy source.
Energy Isolation
Device: A mechanical device that is part of a piece
of equipment, machinery or system that physically prevents the transmission or release of energy. Some examples include manually operated electrical
circuit breakers; disconnect switches, slide gates, line valves and blocks.
Energy Source:
An "energy source" is any source of electrical, mechanical, hydraulic, pneumatic, chemical, thermal, or other energy.
Locks: An individually keyed padlock personally assigned to an Authorized Person or Affected Person that is used with a lock out device to control and isolate
energy sources.
LOTO: Lock out Tag
Out
Lock Out: The placement of a Lock out Device including a padlock on the Energy
Isolating Device of a piece of equipment, machinery or system.
The placement is done in accordance with the department’s established procedures to ensure the energy isolation
device and equipment being controlled cannot be
operated until the lock out device is removed. Only the Authorized Person who placed the lock on can remove it (under
control PTW system) at the completion
of the job. Procedures must include those conditions when personnel other that
the Authorized Person can also be
affected by accidental release of hazardous energy. An example would be multiple personnel performing
work activities in a controlled space (e.g., electrical power has been secured to a work area, equipment, machinery or
system). During Lock outs by multiple
personnel, the equipment, machinery or system must remain secured until the
last Authorized or Affected personnel has completed his work task and has removed his lock.
Lock Out Device: A device that uses a positive means such as a lock to hold an Energy Isolation Device safely and prevent the
start up of a machine or equipment. Lock Out devices include valve wheel covers, ball valve locks, locks for circuit
breakers, and plug and switch plate
locks.
POGC: Pars Oil & Gas Company
Servicing or
Maintenance Activities: Workplace activities that
include but are not limited to: installing, setting
up, inspecting or maintaining equipment; and lubrication, cleaning
and making tool changes where
the employee may be exposed to the unexpected energizing of the equipment
or release of hazardous energy.
SWI: Safe Working
Instruction
Tag Out: Posting a prominent warning tag with durable string onto the energy
isolation device and/or lock out
device of the piece of equipment, machinery or system being controlled. This tag documents the Authorized Person taking
the equipment out of operation and the date. It is a warning to others that the equipment cannot be put back into
operation until the tag and lock under control of PTW system have been
removed by the Authorized Person.
Zero Mechanical State: The mechanical
potential energy of all portions of the equipment or machine is set so that the opening of pipes, tubes, hoses or
actuation of any valve, lever or button, will not produce a movement which could
cause injury
8.
REFERENCES :
OSHA Hazardous Energy
Control Standard - CFR 1910.147
9.
APPENDIXES :
APPENDIX 1 : FLOW CHART FOR THE ISOLATION
OF MACHINERY/EQUIPMENT APPENDIX
2 : A GUIDE TO ISOLATION DEVICES AND THEIR USE
APPENDIX 3 : GENERAL LOCKOUT
GUIDELINES ACCORDING TO ENERGY FORMS AND SOURCES*
APPENDIX 4 : TAG SAMPLE
APPENDIX 1 : FLOW CHART FOR THE ISOLATION
OF MACHINERY/EQUIPMENT
•
|
Refer SWI
•
Disconnect
portable machinery/equipment from power point
|
(if safe to do so)
Initial isolation
– 'Caution'
tag
•
Inform laboratory
/studio/workshop supervisor
•
|
Ensure tag is in prominent
position
•
Replaces tag with own if required
•
Ensures isolation is adequate
•
Uses appropriate hierarchy of controls to isolate
Machinery/equipment repair isolation – 'Danger' tags
Each individual working on machinery/equipment:
•
|
ensures isolation is adequate
•
uses appropriate hierarchy of controls to isolate
•
may only remove
their own
|
'Danger' tag
•
may remove
'Caution' tag to repair machinery/equipment
Re
activate machinery/equipment – removal of tags
•
Refer to SWI
•
|
Ensure all energy sources are clear and safe to activate
•
All protective guarding and interlocks must be operational
 |
|||
 |
|||
APPENDIX 2: A GUIDE TO ISOLATION
DEVICES AND THEIR
USE
|
Isolation Device |
Description of use |
|
Caution tag:
|
Yellow and black
tag: •
Used for out of service
machinery/equipment. • May be removed by
appropriate service people, personnel, or supervisor after
consultation and once machinery/equipment is deemed safe for repair and testing purposes. •
May be used by any person to indicate a fault in machinery. •
Tagged machinery/equipment must not be used. •
Hierarchy of control level - Administrative |
|
Danger tag:
|
Red white
and black tag: •
Used to protect personnel and machinery/equipment. •
May only be removed
by the personnel who placed and signed the
tag. •
May be removed once machinery/equipment is deemed safe or the individual has completed their
task. • Multiple tags must be used; one for each
individual. •
Tagged machinery/equipment must not be used. •
Hierarchy of control level - Administrative |
|
Locking device:
|
Isolation pad locks: •
Used to protect personnel and machinery/equipment in conjunction with
tags. •
May only be removed
by the personnel who placed and signed the
tag. •
May be removed once machinery/equipment is deemed safe or the individual has completed their
task. • Multiple locks
must be used;
one for each
individual. •
Hierarchy of control
level - Engineering |
|
Isolation Clasps:
|
Isolation Clasps: •
Used in conjunction with multiple locks
and tags. •
Each lock on a
clasp represents each
individual. •
Hierarchy of control
level - Engineering |
|
Physical restraint devices
|
Physical restraint devices •
Used in conjunction with clasps locks
and tags. •
Use to reduce the likelihood of misuse of machinery/equipment or accidental energising. • Hierarchy of control level
- Engineering |
APPENDIX 3 :GENERAL LOCKOUT GUIDELINES ACCORDING TO
ENERGY FORMS AND SOURCES*
|
ENERGY FORM |
ENERGY SOURCE |
GENERAL LOCKOUT GUIDELINE |
|
Electricity |
•
power transmission lines •
machine power cords •
motors •
solenoids •
capacitors (stored electrical energy) •
generators •
batteries •
photovoltaic arrays |
•
Shut off power at machine first (point of operation switch), and then at main disconnect switch for machine; lock and tag main disconnect switch (or remove fuses from box, and then lock
and tag box).
•
Fully discharge all
capacitative systems (e.g. cycle machine to drain power
from capacitors) according to manufacturer’s
instructions. |
|
Fluid Pressure |
•
Hydraulic systems -
hydraulic presses -
rams -
cylinders -
hammers |
•
Shut off, lock (with chains, built-in lockout devices, or lockout attachments) and
tag valves; bleed off fluid and
blank lines as necessary. |
|
Air Pressure |
•
Pneumatic systems: -
lines -
pressure reservoirs -
accumulators -
air surge tanks -
rams -
cylinders |
•
Shut off, lock (with chains, built-in lockout devices, or lockout attachments) and
tag valves; bleed off excess air. If pressure cannot be relieved, block any possible movement of machinery. |
|
Kinetic Energy (energy of a
moving object or materials - moving
object may be
powered or coasting) |
•
blades •
flywheels •
materials in supply lines of bins
or silos |
•
Stop and block machine parts, and ensure that they do not recycle. Review entire cycle of mechanical motion; ensure that all motions are stopped.
•
Block material from
moving into area of work
and blank as required. |
|
Potential Energy
(energy stored in an object with the potential for release due to its position) |
•
springs •
actuators •
counterweights •
raised loads •
top or movable
part of a press or lifting device |
•
If possible, lower
all suspended parts
and loads to the lowest (rest) position, block
parts that might move due to
gravity; release or block stored spring energy. |
|
Pressurized liquids and gases (including
steam, chemicals) |
•
supply lines •
storage tanks and
vessels |
•
Shut off, lock (with chains, built-in lockout devices, or lockout attachments) and
tag valves; bleed off excess
liquids or gases; blank lines
as necessary. |
* adapted from “A Health and Safety Guideline for your Workplace,” Industrial Accident Prevention Association, 2000
APPENDIX 4 :TAG Sample
 |
 |
SUGGESTIONS FOR THE POGC
LOCK OUT TAG OUT PROCEDURE
MANAGER, HSE Department Pars Oil & Gas Company
Tehran I.R. Iran
Please
consider the following suggestion(s) relative to the POGC Lock out Tag
out procedure:
 |
 |
(Signature)
 |
(Date)
 |
(Address)
 |
Contact Telephone
Number
 |
Contact FAX Number
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