Ruj.

Kami: (36)PSMB/1/14/13 Kulit 2

Tarikh : 16 Januari 2014

PEKELILING PENYEDIA LATIHAN BIL. 1/2014

TERMA DAN SYARAT BARU BAGI PENDAFTARAN PENYEDIA LATIHAN,

PROGRAM LATIHAN DAN KURSUS

1.0

TUJUAN
1.1

Tujuan pekeliling ini adalah untuk memaklumkan mengenai terma

dan syarat baru bagi pendaftaran penyedia latihan, kursus dan
program latihan. Langkah ini diambil bagi memastikan hanya
program latihan dan kursus yang berkualiti sahaja layak ditawarkan
di

bawah

Kumpulan

Wang

Pembangunan

Sumber

Manusia

(KWPSM).
2.0

LATAR BELAKANG

2.1

Ahli Lembaga Pengarah PSMB melalui mesyuarat pada 16 Disember

2013, telah meluluskan pelaksanaan terma dan syarat baru, proses
dan prosedur bagi pendaftaran baru penyedia latihan, pendaftaran
semula penyedia latihan dan juga pendaftaran program dan kursus.

2.2

Keputusan ini dibuat bagi memastikan hanya program latihan dan

kursus berkualiti sahaja layak untuk mendapat bantuan kewangan di
bawah KWPSM.

2.3

Selain itu, langkah ini diambil bagi menyokong hasrat Kerajaan ke

arah mencapai sasaran 50% tenaga kerja mahir menjelang tahun
2020.

3.0

TEMPOH PERALIHAN (2014)

3.1

Tahun 2014 adalah merupakan tempoh peralihan

di mana

pendaftaran semula penyedia latihan dan pendaftaran program

dilaksanakan. Ianya dijadualkan selesai pada 31 Disember 2014.
Sepanjang tempoh peralihan ini, hanya program latihan dan kursus
di bawah skim SBL dan SBL Khas yang dibenarkan ditawarkan oleh
penyedia latihan kepada majikan berdaftar. Semua program latihan
dan kursus yang telah diluluskan di bawah skim PROLUS/PERLA
akan ditukarkan statusnya kepada SBL Khas.

4.0

PENDAFTARAN PENYEDIA LATIHAN

4.1

Terma dan syarat baru pendaftaran penyedia latihan adalah seperti

berikut :a)

Diperbadankan di bawah Suruhanjaya Syarikat Malaysia

dan mempunyai salah satu status seperti berikut;

i) Berhad (Bhd.) / Sendirian Berhad (Sdn. Bhd.);

ii) Persatuan / Pusat latihan berdasarkan industri; atau
iii) Kerajaan / Institusi Separa Kerajaan
b)

Mempunyai

sekurang-kurangya

seorang

pengajar

tetap

tempatan; dan
c)

Diiktiraf

oleh

badan

persijilan

(Jabatan

Pembangunan

Kemahiran (JPK), Malaysian Qualification Agency (MQA),

SIRIM,

Department

of

Safety

and

Health

(DOSH),

Suruhanjaya Tenaga dll.) atau mempunyai program latihan

dan kursus persijilan yang diiktiraf;
4.2

Permohonan perlu dikemukakan menerusi borang PSMB/TP/1/14

(Rujuk Lampiran 1). Permohonan hendaklah disokong dengan
dokumen berkaitan yang mana akan disemak oleh Pegawai PSMB
semasa lawatan verifikasi ke premis latihan.

4.3

Yuran

pemprosesan

adalah

sebanyak

RM3,000.00

manakala

yuran pemprosesan bagi setiap cawangan pula dikenakan sebanyak

RM1,500.00. Bagi penyedia latihan yang telah berdaftar, yuran
pemprosesan

bagi

pendaftaran

semula

adalah

sebanyak

RM1,200.00 untuk ibu pejabat dan RM600.00 dikenakan untuk setiap

cawangan (semasa tempoh peralihan). Yuran pemprosesan

tidak

akan dikembalikan.

4.4

Tempoh sah pendaftaran adalah selama tiga (3) tahun.

4.5

Kriteria yang akan dinilai oleh Jawatankuasa Penilaian adalah seperti

berikut:a)

Visi dan strategi organisasi;

b)

Pembangunan & pengurusan program latihan dan

kursus;

c)

Kemudahan bilik latihan dan peralatan latihan;

d)

Program latihan dan kursus yang akan ditawarkan

kepada majikan dan

e)
4.6

Infrastruktur dan kakitangan sokongan.

Permohonan pendaftaran baru dan pendaftaran semula boleh

dikemukakan kepada PSMB bermula 15 Januari 2014. Penilaian
pendaftaran penyedia latihan akan diadakan pada setiap suku
penggal seperti yang berikut:Tempoh penilaian

4.7

Tempoh penghantaran

a)

Suku Pertama

Januari Februari

b)

Suku Kedua

April Mei

c)

Suku Ketiga

Julai Ogos

d)

Suku Keempat

Oktober November

Jika penyedia latihan yang sedia ada gagal untuk mendaftar semula
pada tahun 2014, sijil pendaftaran mereka akan dibatalkan pada 1
Januari 2015.

4.8

Penyedia latihan perlu mengemukakan permohonan pembaharuan

pendaftaran tiga (3) bulan sebelum tarikh tamat sijil. Kriteria yang
akan dinilai bagi pembaharuan adalah seperti yang berikut:a)

Penyedia latihan mesti aktif menjalankan latihan kepada

majikan berdaftar;

b)

Laporan Prestasi Penyedia Latihan; dan

c)

Bilangan borang penilaian kursus yang dihantar (atas

talian) ke PSMB berbanding dengan bilangan sesi latihan
yang dijalankan di bawah skim PSMB.

4.9

Yuran pemprosesan bagi pembaharuan penyedia latihan adalah

RM3,000.00 manakala RM1,500.00 pula dikenakan untuk setiap
cawangan. Yuran pemprosesan ini tidak akan dikembalikan

5.0

PENDAFTARAN PROGRAM LATIHAN DAN KURSUS

5.1

Berkuatkuasa pada 1 Januari 2014, Skim PROLUS dan PERLA akan

dimansuhkan. Manakala Skim SBL- Khas pula akan dimansuhkan
pada 31 Disember 2014. Berkuatkuasa pada 1 Januari 2016, semua
program latihan dan kursus mesti mendapat kelulusan daripada
PSMB sebelum ianya ditawarkan kepada majikan berdaftar.

5.2

Bagi memohon kelulusan program latihan dan kursus, penyedia

latihan dikehendaki mengemukakan dokumen seperti yang berikut:-

a)

Manual latihan yang komprehensif (kecuali bagi kursus

latihan program yang telah diakreditasi oleh Jabatan
Pembangunan

Kemahiran

(JPK)

atau

Malaysian

Qualification Agency (MQA));

b)

Tajuk program latihan dan kursus;

c)

Tempoh latihan (mesti melebihi tujuh (7) jam);

d)

Objektif program latihan dan kursus;

e)

Kumpulan Sasaran (mengikut jawatan);

f)

Industri yang disasarkan;

g)

Rangka program latihan dan kursus;

h)

Kaedah latihan;

i)

Biodata pengajar (pengajar yang mempunyai sijil Train

The Trainer PSMB atau telah dibenarkan untuk
berdaftar sebagai pengajar.

j)

5.3

Yuran Kursus.

Permohonan perlu dikemukakan menerusi borang PSMB/PRO/1/14

(Rujuk Lampiran 2). Permohonan perlu disokong dengan dokumen
berkaitan yang akan disemak oleh Pegawai PSMB semasa lawatan
verifikasi ke premis latihan.

5.4

Kriteria yang akan dinilai oleh jawatankuasa adalah seperti berikut:a)

Perincian mengenai kandungan kursus;

b)

Latar belakang dan pengalaman pengajar bagi bidang

yang diajar;

c)

Kesesuaian yuran latihan berdasarkan modul, tahap

dan isi kandungan kursus yang mana akan dinilaikan
dan dibuat perbandingan berdasarkan amalan industri;

5.5

Yuran pemprosesan yang dikenakan adalah RM500.00 bagi setiap

program dan tidak akan dikembalikan. Tempoh sah pendaftaran
adalah tiga (3) tahun.

5.6

Bagi

tahun 2014 dan

2015,

permohonan

bagi pendaftaran

kursus/program latihan boleh dikemukakan kepada PSMB mengikut

tempoh masa seperti yang berikut:-

5.7

a)

April 2014 Jun 2014

b)

Ogos 2014 Oktober 2014

c)

Disember 2014 Februari 2015

d)

April 2015 Mei 2015

e)

Julai 2015 Ogos 2015

f)

Oktober 2015 November 2015

Bermula 1 Januari 2016 dan seterusnya, permohonan untuk

pendaftaran program latihan akan dibuka pada April hingga Mei dan
Julai hingga Ogos setiap tahun.

5.8

Permohonan untuk pembaharuan pendaftaran program latihan dan

kursus hendaklah dibuat tiga (3) bulan sebelum tarikh tamat. Kriteria
yang akan dinilai bagi pembaharuan adalah seperti yang berikut:-

a)

Penyedia latihan mesti aktif menjalankan latihan

tersebut kepada majikan berdaftar sekurang-kurangya
lima (5) kali dalam tempoh dua (2) tahun;

b)

Laporan

penilaian

majikan

(pelatih)

yang

telah

menghadiri program/kursus latihan tersebut;

c)

Maklumbalas daripada Sectorial Training Committees

(STCs) samada program latihan atau kursus tersebut
adalah

relevan

keperluan industri.

serta

memenuhi

kehendak

dan

5.9

Yuran pemprosesan bagi pembaharuan program latihan adalah

sebanyak RM500.00 dan tidak akan dikembalikan. Tempoh sah
pendaftaran adalah tiga (3) tahun.

6.0

TARIKH KUATKUASA
6.1

7.0

Pekeliling ini berkuatkuasa pada 15 Januari 2014.

PENUTUP
7.1

Adalah diharapkan dengan pelaksanaan Terma dan Syarat Baru bagi

Pendaftaran Penyedia Latihan, Program Latihan dan Kursus, hanya
program latihan yang berkualiti sahaja layak untuk mendapat
bantuan kewangan di bawah KWPSM.

7.2

Sebarang pertanyaan lanjut, boleh menghubungi Unit Khidmat

Pelanggan di talian 1-800-88-4800.

Terima kasih.
HRDF-SHAPING PEOPLE
PEKERJA PEMANGKIN TRANSFORMASI NEGARA
Yang ikhlas,

( ALI BADARUDDIN BIN ABD KADIR )

Ketua Eksekutif
Pembangunan Sumber Manusia Berhad

LAMPIRAN 1

PSMB/TP/1/14

TRAINING PROVIDER REGISTRATION FORM

PSMB OFFICER USE :

MyCoID

All items in this form must be completed. Where the space prov ided is inadequate, please prov ide the information on a separate
sheet and attach it to the form. Where information is not yet av ailable or not applicable, please indicate accordingly. All
information giv en will be treated as confidential.
CHECKLIST
1) Completely filled Form PSMB/TP/1/14.
2) A copy of Memorandum and Article of Association of the company that reflected one of the clauses of the company is
"training and consultancy services".
3) A copy of tenancy agreement / ownership of property (under company's name or owner) together with stamping etc.
for v erification of company premise.
4) A list of name(s) of supporting staff and their I.C Number(s).
SECTION A: COMPANY PROFILE
1) Name and Address of Training Inst it ut ion/Provider. Please use CAPITAL LETTER
NAME :

ADDRESS OF BUSINESS :

POSTCODE :

STATE :

OFFICER -IN-CHARGE :

TEL. :

FAX:

E-MAIL:

2) Types of Organisat ion. Please t ick ( / ) in t he appropriat e box

a)

BERHAD (BHD.) / SENDIRIAN BERHAD (SDN. BHD.)

b)

ASSOCIATION / INDUSTRY-BASED TRAINING CENTRE

c)

GOVERNMENT / SEMI GOVERNMENT INSTITUTION

c)

JOINT VENTURE

3) Types of Ownership. Please t ick ( / ) in t he appropriat e box

a)

100% LOCAL

b)

100% FOREIGN

Please attach a copy of registration of company/business/association from SSM (Suruhanjaya Syarikat Malaysia).
E.g : (Form 9, 24, 49) / (Form 8, 49) / (Form E, Business, Ownership)
SECTION B: CERTIFICATION
Please t ick ( / ) in t he appropriat e box
1) Is your centre accredited by any certification body/authority?

YES

NO

YES

NO

If Yes, please specify:

2) Is your centre offers any certification programme?
If Yes, please specify one of the programme:
Please attach evidence of certification

SECTION C: TRAINING COMPETENCY

1) Please specify your organisat ion's vision, mission, st rat egy and development of t raining courses. (Please complet e
Appendix A)
2) Please provide t he det ails of t raining programme t hat will be offered. (Please complet e Appendix B )
3) Please st at e t he number of t rainers in t he given box.
Full Time :

Part-Time :
Please attach biodata of trainers (Please complete Appendix C)
SECTION D: QUALITY SYSTEM

1) Please specify any qualit y syst em implement ed: (e.g.: ISO Cert ificat ion, 5S Cert ificat ion, Evaluat ion Of Training
Effect iveness, Evaluat ion Of Cust omer Sat isfact ion)
1)
2)
3)
Please attach separate list if more than the above given space
SECTION E: PAYMENT
Processing Fee (New Registration - RM3000, New Branch RM1500) in the form of cheque or money postal made payable to
PEMBANGUNAN SUMBER MANUSIA BERHAD .
Cheque No. :

Money Postal
Amount :

Date :

(The processing fee is non-refundable should the application is rejected)

SECTION F: COMPANY DECLARATION
We declare that the facts stated in this application form and the accompanying information are true and correct and that
we hav e not withheld/distorted any material facts. We understand that if we obtain the approv al status by false or
misleading statements, we may be prosecuted under Section 41 of Pembangunan Sumber Manusia Berhad Act 2001 (Act
612) and in addition, Pembangunan Sumber Manusia Berhad may, at its discretion, withdraw the approv al status

SIGNATURE :

SIGNATURE :

NAME & DESIGNATION :

(Chairman/Managing Director/General

NAME & DESIGNATION :

(Officer-in-charge)

Manager)
Com pany Stam p:

PSMB OFFICER REMARKS :

Signature :
Name :
Date :

APPENDIX A
TRAINING PROVIDER REGISTRATION FORM
(TRAINING PROVIDER COMPETENCY)

A.
1.

CORPORATE STRATEGY
Please State the of the company with regard to its Vision, Mission, Objectives, Core Values, Corporate
Strategy and Quality Policy.
i)

Vision :

ii)

Mission :

iii) Objectives :
iv) Core Values :
v)

Corporate Strategy :

vi) Quality Policy :

2.

Please explain the method of formulating the corporate strategy (You are required to explain the process
and provide evidence during the verification visit).

B.

TRAINING PROGRAM DEVELOPMENT

1.

Please state the method of developing training programmes including its curriculum structure to meet
industry requirements.

2.

Describe the approaches implemented by your company in ensuring quality training programmes.

i)

Identification of training needs of employers/industries

(Please attach any study, market intelligence or survey conducted).

ii)

Internal factors, including upgrading of trainers skills

(Please provide evidence).

3.

Briefly explain the effort put for continuous improvement of the training programmes.

APPENDIX B
TRAINING PROVIDER REGISTRATION FORM
(LIST OF TRAINING PROGRAMME)

1.

2.

3.

Title of course / programme

Duration
(must be more than seven (7) hours)

Target Group (by designation)

4.

Targeted industry/industries for

the courses

5.

Certification

6.

Course Objective

7.

Course Content/Outline

Indicate who provide the Certification of

the programme in this column, if relevant.

Please check the example in the format as per Appendix B1

APPENDIX B1

EXAMPLE OF LIST TRAINING PROGRAMME

1.

TITLE OF COURSE / PROGRAMME

Project Management Professional (PMP) certification preparatory program

2.

DURATION
35 hours

3.

TARGET GROUP (BY DESIGNATION)

This preparatory program is for those who are already in the project management field at
any level and need to become a certified project manager via Project Management
Institute, USA

4.

TARGETED INDUSTRY/INDUSTRIES
Administration, Art, Banking, Bioengineering, Biotechnical, Computers, Construction,
Consulting, Customer Service, Education, Engineering, Finance, Government, Healthcare,
Hospitality, Hospitals, Human Resources, Information Systems, Information Technology,
Insurance, Law Enforcement, Legal, Logistics, Manufacturing, Media Communication
(advertisement, print, radio, TV), Oil and Gas, Plantation, Public Relations, Purchasing,
Quality Assurance, Quality Control, Quality Testing, Software Development, Supply Chain,
Training, etc.

5.

CERTIFICATION
PMP certification by PMI after passing exam.

6.

COURSE OBJECTIVE
This training activity is for those individuals who are already in the field of project
management and want to sit for the PMP certification examination.

7.

COURSE OUTLINE
1
2
3
4
5
6
7
8
9
10
11
12
13

Introduction, Organizational Influences and Project Life Cycle

Project Management Processes
Project Integration Management
Project Scope Management
Project Time Management
Project Cost Management
Project Quality Management
Project Human Resource Management
Project Quality Management
Project Risk Management
Project Procurement Management
Project Stakeholder Management
Professional and Social Responsibility

APPENDIX C
TRAINING PROVIDER REGISTRATION FORM
(TRAINERS BIODATA)

Full Time
Part Time

Trainer Status. Please tick ( / ) in

the appropriate box

A.

TRAINERS BACKGROUND
NAME

I/C NO

NATIONALITY

TELEPHONE NO.

EMAIL ADDRESS

B.

ACADEMIC QUALIFICATION

C.

PROFESSIONAL QUALIFICATION

D.

YEARS OF CAREER EXPERIENCE

* Please include the breakdown of designations held according to year as follows:

Year

E.

Previous Company

EXPERIENCE IN TRAINING

Position

* Please include the breakdown of training programme conducted according to year as

follows:
Year

F.

Name of Training Programme Conducted

CURRENT OCCUPATION

*TRAINERS SIGNATURE : ___________________________

DATE

: ___________________________

* Trainer is required to sign this column. Any application without trainers own signature will be rejected

LAMPIRAN 2

PSMB/PRO/1/14

APPLICATION FOR TRAINING PROGRAMME APPROVAL

PSMB OFFICER USE :

Name of Training Provider :

Officer-in-Charge

:.

Telephone. No.

:.

Please attach the following documents:

Cover Letter using your company letter head
Copy of Bank in Slip of RM500.00 for each training programme payable at
Public Bank Berhad (PBB) to account no. 3 9990600 03

A set of Appendix A on the training courses/programme outline

A set of Appendix B on Bioadata of the Trainers (All trainers must have attended PSMB
Train-The-Trainer course or granted exemption by PSMB. At least 2 trainers required for each
training programme

A copy of comprehensive training manual (Except for training courses/programme

accredited by Jabatan Pembangunan Kemahiran (JPK) or Malaysian Qualification
Agency (MQA))

Authorised letter to use training manual if the training manual is prepared/owned

by others
Authorised letter from the Ministry of Education / MQA / Institution of
Higher Learning from local or overseas for Development Programme
(Diploma, Degree, Master and PhD)

CD / DV or other simulation equipment which will be used during the training

programme (If applicable)

Please refer to the example in the format as per Appendix A2, A3 & B.

APPENDIX A

MyCoID

TRAINING PROGRAMME OUTLINE

1.

Title of training course/programme

2.

Type of Programme

Please tick ( / ) one:Technical

3.

Skills Area
Please select one of the skills area for the training
course/programme based on the list in Appendix A1

4.

Duration
(must be more than seven (7) hours)

5.

Target Group (by designation)

6.

Targeted
courses

7.

industry/industries

for

the

Certification
Please state the certification body if applicable and the
supporting evidence

8.

Course Objective

9.

Training Methodology

10.

Course Content/Outline
Please attach using the format as per Appendix A2
Please attach comprehensive training manual. Kindly
take note that Power Point slide will not be
considered as manual

11.

Course Fee (RM)

Please provide breakdown of the course fee.
For certification or development programme, please
breakdown the course fee into trainers fees based on
modules. Refer to the sample as per Appendix A3
The fee for public programme
participants and in total costs basis

MUST be

by

Non-Technical

APPENDIX A1

LIST OF SKILLS AREA

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

Technical
Computer / IT
Quality / Productivity
Management
Human Resource
Finance / Accounting
Supervisory
Administration
Communication / Public Relation
Language
Safety & Health
Law
Executive Development Programme
Clerical Development Programme
Sales & Marketing
Diploma Programme
Degree Programme
Master Programme
PhD. Programme
SKM Programme
Industrial Relation
Purchasing / Store / Warehouse
Operation Management
Creativity & Innovation
R&D
Medical
Others (Please state)

APPENDIX A2
MyCoID

EXAMPLE OF COURSE CONTENT/OUTLINE

1.

TITLE OF COURSE / PROGRAMME

Project Management Professional (PMP) certification preparatory program

2.

DURATION
35 hours

3.

TARGET GROUP (BY DESIGNATION)

This preparatory program is for those who are already in the project management field at
any level and need to become a certified project manager via Project Management
Institute, USA

4.

TARGETED INDUSTRY/INDUSTRIES
Administration, Art, Banking, Bioengineering, Biotechnical, Computers, Construction,
Consulting, Customer Service, Education, Engineering, Finance, Government, Healthcare,
Hospitality, Hospitals, Human Resources, Information Systems, Information Technology,
Insurance, Law Enforcement, Legal, Logistics, Manufacturing, Media Communication
(advertisement, print, radio, TV), Oil and Gas, Plantation, Public Relations, Purchasing,
Quality Assurance, Quality Control, Quality Testing, Software Development, Supply Chain,
Training, etc.

5.

CERTIFICATION
PMP certification by PMI after passing exam

6.

COURSE OBJECTIVE
This training activity is for those individuals who are already in the field of project
management and want to sit for the PMP certification examination.

7.

TRAINING METHODOLOGY
Lecture
Class room discussions
Group discussions
Case studies

8.

COURSE OUTLINE
1
2
3
4
5
6
7
8
9
10
11
12
13

Introduction, Organizational Influences and Project Life Cycle

Project Management Processes
Project Integration Management
Project Scope Management
Project Time Management
Project Cost Management
Project Quality Management
Project Human Resource Management
Project Quality Management
Project Risk Management
Project Procurement Management
Project Stakeholder Management
Professional and Social Responsibility

9.

COURSE FEE (Provide breakdown of the course fee)

RM 4,000/per pax
e.g

ITEM
Tuition Fee

FEE (RM)
3000.00

Administrative Fee

500.00

Exam Fee

300.00

Material

200.00

TOTAL

4000.00

*Item is based on training providers actual expenses.

APPENDIX A3
MyCoID

SAMPLE BREAKDOWN OF THE COURSE FEE, TRAINER

AND TRAINING HOURS BASED ON MODULE FOR CERTIFICATION TRAINING
PROGRAMME / DEVELOPMENT PROGRAMME
MODULE

TOPIC

DURATION OF TRAINING
(HOURS)

COURSE FEE FOR EACH

MODULE (RM)

1.
2.
3.
4.
5.
6.
TOTAL

Computer Technology and Systems

Business Communication
Business System
Computer Programming Methodology
Integrated Programming Project
Multimedia Development
600

100
100
100
100
100
100
6000

1000
1000
1000
1000
1000
1000

TRAINERS LIST
No.
1.

2.

Name of Trainers
Ahmad bin Ismail

Salmah binti Jaafar

Module

Qualification
(Field of Study)

i.
ii.

Business Communication
Quantitative Techniques
for Information Technology
iii.
Multimedia Development

i.

Business
System
Multimedia Development
ii.
Computer Programming
Methodology
iii.
Integrated Programming
Project

Name of Institution of
Higher Learning

MSc Information
Technology

Universiti Sains
Malaysia

BSc (Education)

Universiti Sains
Malaysia

Diploma in
Management

Malaysian Inst. Of
Management

MSc Information
Technology

Universiti Sains
Malaysia

B. Information
Technology

Universiti Utara Malaysia

APPENDIX B
MyCoID

TRAINERS BIODATA
A.

TRAINERS BACKGROUND
NAME

I/C NO

NATIONALITY

TELEPHONE NO.

EMAIL ADDRESS

B.

ACADEMIC QUALIFICATION

C.

PROFESSIONAL QUALIFICATION :

D.

YEARS OF CAREER EXPERIENCE:

Please include positions held according to year as follows:
Year

E.

Previous Company

Position

EXPERIENCE IN TRAINING
Please include all training programmes conducted according to year in table as follows:
Year

F.

Training Programme Conducted

CURRENT POSITION :

*TRAINERS SIGNATURE
DATE

: ___________________________
: ___________________________

* Your signature is a mandatory requirement.