In Re: Gardasil Products Liability Litigation

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UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036- RJC
IN RE: GARDASIL PRODUCTS
LIABILITY LITIGATION
MDL No. 3036
THIS DOCUMENT RELATES
TO ALL CASES
DEFENDANT FACT SHEETS ORDER
I. SCOPE OF ORDER
This Defendant Fact Sheets Order (“DFSO”) governs the form and schedule for service
of Defendant Fact Sheets (“DFS”) by Merck & Co., Inc. and Merck Sharp & Dohme LLC
(collectively, “DEFENDANTS”) in all cases that were (1) transferred to this Court by the
Judicial Panel on Multidistrict Litigation (“JPML”) pursuant to its August 4, 2022 Order; (2)
subsequently transferred to MDL 3036 by the JPML pursuant to Rule 7.4 of the Rules of
Procedure of that Panel; or (3) originally filed in, transferred to, removed to, or reassigned to
MDL 3036. Collectively, these cases shall be referred to as “Subject Actions.”
II. DEFENDANT FACT SHEETS
A. Instructions for Completion and Service of DFS and Production of
Responsive Documents
The form of DFS that shall be used in MDL 3036 for all Subject Actions is attached
as Exhibit A. In accordance with the schedule and provisions set forth in Section II.B. below,
DEFENDANTS shall, for each Subject Action in which a Plaintiff serves DEFENDANTS
with a substantially complete Plaintiff Fact Sheet (“PFS”) Part I and Part II, complete and
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execute a DFS and produce to Plaintiff in the Subject Action all records required under the
DFS. Part I and Part II of the PFS must include the Plaintiff’s name(s) or address(es), the
Plaintiff’s HEALTH CARE PROVIDER’s name(s), the Plaintiff’s HEALTH CARE
PROVIDER(s) address(es) and the GARDASIL/GARDASIL 9 lot number(s). DEFENDANTS
will be unable to provide responses to certain sections of the DFS if this information is not
provided in the PFS. The questions and requests for production contained in the DFS are
non-objectionable and shall be answered fully unless information is privileged or protected
by the attorney-client privilege.
DEFENDANTS’ responses to the DFS shall be treated as answers to interrogatories
under Federal Rule of Civil Procedure 33 and responses to requests for production of documents
under Federal Rule of Civil Procedure 34 and shall be supplemented in accordance with Federal
Rule of Civil Procedure 26. The completed DFS will be governed by the standards applicable
to written discovery under Federal Rules of Civil Procedure 26 through 37. The above does not
prohibit DEFENDANTS from withholding or redacting information on the basis of a recognized
privilege. To the extent DEFENDANTS withhold any information on the ground of privilege,
DEFENDANTS shall identify the privilege being asserted in a privilege log to be produced
pursuant to the Privilege Log Protocol to be negotiated and entered in MDL 3036. Post-
complaint materials need not be logged. Furthermore, the production of responsive
documents should comply with the requirements of the Pretrial Order regarding Electronically
Stored Information (Doc. No. 96). The DFS and responsive documents will be subject to the
Stipulated Protective Order (Doc. No.70) entered in this matter.
Nothing in the DFS shall be deemed to limit the scope of inquiry at depositions or the
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admissibility of evidence at trial. Each completed DFS shall be verified, signed and dated by
someone authorized to sign on behalf of the DEFENDANTS as if it were interrogatory responses
under Federal Rule Civil Procedure 33.
B. Timing and Service of DFS
1. Deadline for Serving a DFS
In all Subject Actions, DEFENDANTS shall complete and serve a DFS for each
Plaintiff no later than forty-five (45) days from the date on which each Plaintiff serves his
or her substantially complete Plaintiff Fact Sheet (“PFS”) Part II or an amended PFS
Part II pursuant to Plaintiff Fact Sheets Order (“PFSO”) (Doc. No. 78). An alleged
deficiency in the PFS will not delay service of the DFS; however, Part I and Part II of the
PFS must include the Plaintiff’s name(s) or address(es), the Plaintiff’s HEALTH CARE
PROVIDER’s name(s), the Plaintiff’s HEALTH CARE PROVIDER(s) address(es) and the
GARDASIL/GARDASIL 9 lot number(s). DEFENDANTS will be unable to provide responses
to certain sections of the DFS if this information is not provided in the PFS.
If a Plaintiff has received (1) an “Alert of Non-Compliance with PFS – Part I
Requirements”; or (2) an “Alert of Non-Compliance with PFS – Part II Requirements”
due to a Plaintiff’s failure to serve a PFS Part I or Part II, then DEFENDANTS obligation
to complete and serve a DFS for that Plaintiff does not begin to run until: (1) Plaintiff provides
a substantially complete PFS Part I and II; (2) DEFENDANTS’ Motion to Compel a
complete PFS Part I or Part II has been resolved by the Court; or (3) by agreement of the
Parties.
Notwithstanding Section B.1., above, the Parties will separately negotiate, at a
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later date, any additional requests in each of the Actions later selected as a Bellwether
case in this MDL.
2. Service of the DFS
All completed DFS and responsive records and materials will be (a) served
directly on the individual Plaintiff’s counsel of record who served the PFS triggering
the DFS obligation, using the email address(es) identified on the individual case docket
in the U.S. District Court for the Western District of North Carolina’s ECF system and
(b) a courtesy copy shall be produced to the designee of the Plaintiffs’ Steering
Committee at GardasilDFS@LanierLawFirm.com.
C. Claims by Plaintiff That a DFS Is Not Substantially Complete and/or
Contains Material Deficiencies and/or DEFENDANTS’ Failure to Submit
a DFS.
1. Not Substantially Complete and/or Contains Material Deficiencies
In the event that a Plaintiff contends that a DFS, and responsive documents
produced pursuant to the DFS, is not substantially complete and/or contains material
deficiencies, the individual Plaintiff’s counsel of record shall notify DEFENDANTS’
counsel of the purported deficiency(ies) by email at
GardasilDefenseFactSheets@morganlewis.com within thirty (30) days of receipt of the
DFS, which shall identify with specificity the purported deficiencies. Plaintiff’s email
communication shall identify the case name, docket number, deadline date, and shall
state the basis for Plaintiff’s contention that the DFS contains material deficiencies
and/or is not substantially complete.
DEFENDANTS will have thirty (30) days from receipt of a deficiency letter to
cure t h e a l l e g e d deficiencies noted in the DFS and telephonically or virtually meet
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and confer with Plaintiff’s counsel, if DEFENDANTS choose to do so. Failure of
DEFENDANTS’ counsel to meet and confer does not delay DEFENDANTS’ ability
to file motions under this section. A courtesy copy of any email notifying
DEFENDANTS of deficiencies shall be produced to the designee of the Plaintiffs’
Steering Committee at GardasilDFS@LanierLawFirm.com.
In the event that the purported deficiencies have not been cured in this thirty
(30) day period, Plaintiff, through their individually retained counsel, may request to
meet and confer with DEFENDANTS regarding the alleged deficiency(ies). Plaintiff’s
counsel shall notify DEFENDANTS in writing via email of the request to meet and
confer and state that the meet and confer shall occur within fourteen (14) days. The
Parties’ meet and confer period shall begin upon receipt of the email by
DEFENDANTS and, absent agreement of the Parties, shall be completed by the
conclusion of the fourteen (14) days.
Following the meet and confer period, should DEFENDANTS (i) fail to cure
the alleged deficiency(ies); (ii) fail to assert objections with respect to the
requests/questions that are the subject of the claimed deficiencies; (iii) fail to respond
to or participate in the meet and confer process; or (iv) otherwise fail to provide
responses, and absent agreement of the Parties to further extend the meet and confer
period, at any time following expiration of the fourteen (14) day meet and confer, the
individual Plaintiffs’ counsel may file a motion to compel with respect to the allegedly
deficient information.
The filing of a motion to compel made pursuant to this Order shall be via ECF.
A courtesy copy of any motion to compel shall be produced to the designee of the
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Plaintiffs’ Steering Committee at GardasilDFS@LanierLawFirm.com.
DEFENDANTS’ response to a motion to compel made pursuant to this
provision shall be filed and served within fourteen (14) days following the date of
service of the motion. The Plaintiff’s reply, if any, to DEENDANTS’ response shall
be filed within seven (7) days following the date of service of DEFENDANTS’
response in opposition to the motion.
2. Failure to Serve a DFS
Should DEFENDANTS fail to serve an executed DFS within the time required
in this Order, the individual Plaintiff’s counsel shall send a Notice of Non-Compliance
letter via e-mail to DEFENDANTS at GardasilDefenseFactSheets@morganlewis.com.
A courtesy copy shall be produced to the designee of the Plaintiffs’ Steering Committee
at GardasilDFS@LanierLawFirm.com. Following receipt of the Notice of Non-
Compliance letter, DEFENDANTS shall have twenty-one (21) days to serve the DFS.
At any time following the expiration of the twenty-one (21) day period after
DEFENDANTS receive a Notice of Non-Compliance, absent agreement of the Parties
to further extend the period for meeting and conferring, a Plaintiff may move the Court
for an order compelling service of a complete DFS.
Any such filing shall be via ECF. A courtesy copy of the motion to compel shall
be produced to the designee of the Plaintiffs’ Steering Committee at
GardasilDFS@LanierLawFirm.com. DEFENDANTS’ response to a motion to compel
made pursuant to this provision shall be filed and served within fourteen (14) days
following the date of service of the motion. The Plaintiff’s reply, if any, to
DEFENDANTS’ response shall be filed within seven (7) days following the date of
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service of DEFENDANTS’ response in opposition to the motion.
The obligation to take any action authorized in this Order related to deficiencies
in a DFS or failure to serve a DFS shall be the sole obligation of the individual attorney
hired by the individual Plaintiff. Plaintiffs’ Co-Lead Counsel, Liaison Counsel,
Plaintiffs’ Executive Committee, and Plaintiffs’ Steering Committee shall have no
obligation to take any action with regard to the DFS process for any individual Plaintiff.
D. Documents Obtained Designated as Confidential.
Any records served by DEFENDANTS pursuant to this DFSO shall be deemed
confidential under the terms of the Stipulated Protective Order (Doc. No. 70) entered in this
MDL.
SO ORDERED. Signed: June 26, 2023
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EXHIBIT A – DEFENDANT FACT SHEETS ORDER
UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:22-md-03036-RJC
IN RE: GARDASIL PRODUCTS LIABILITY
LITIGATION MDL No. 3036
DEFENDANT FACT SHEET FOR
DEFENDANTS MERCK & CO., INC. AND MERCK SHARP & DOHME LLC
This Defendant Fact Sheet (“DFS”) pertains to Defendants Merck & Co., Inc. and Merck Sharp &
Dohme LLC (collectively “DEFENDANTS”) only.
For each case, DEFENDANTS must complete and serve this DFS pursuant to the terms in the
Defendant Fact Sheets Order (“DFSO”) regarding DFSs. DEFENDANTS shall provide the answers and
responses herein and produce responsive DOCUMENTS pursuant to the Stipulated Protective Order (Doc.
No. 70). Information provided will only be used for purposes related to this litigation and may be disclosed
only as permitted by the Protective Order in this litigation. This DFS is completed pursuant to the Federal
Rules of Civil Procedure governing discovery.
DEFENDANTS’ answers and responses herein are based on available responsive information that
can be reasonably searched and obtained from DEFENDANTS’ readily accessible electronic database(s)
maintained in the ordinary course of business. DEFENDANTS do not have an obligation to review or
produce information for this DFS from any other source, including, but not limited to, department or
custodial files. The Parties will separately negotiate potential custodial file collections and productions in
the 16 cases selected for inclusion in the Initial Bellwether Pool as defined by the First Case Management
Order separate and apart from the DFS. DEFENDANTS reserve the right to supplement these answers and
responses in accordance with the Federal Rules of Civil Procedure and DFSO regarding DFSs.
INSTRUCTIONS
In completing this DFS, each response must provide the substantive information, documents, and
data responsive to the questions set forth below for each Plaintiff. No question shall be left unanswered or
blank unless the information is protected by the attorney-client privilege, the work-product doctrine, or any
other privilege recognized by the Federal Rules of Evidence and Federal Rules of Civil Procedure. If
information is withheld as privileged, a privilege log will be provided pursuant to the Privilege Log Protocol
to be negotiated and entered in MDL 3036. The parties agree that post-complaint materials need not be
logged. In the event this DFS does not provide enough space to complete the responses or answers, please
attach additional sheets if necessary.
In providing answers and responses in this DFS, DEFENDANTS do not have an obligation to
review medical records or any other source of information to identify Plaintiff’s name(s), Plaintiff’s
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addresses(es), Plaintiff’s HEALTH CARE PROVIDER’S name(s), Plaintiff’s HEALTH CARE
PROVIDER’S address(es) or the GARDASIL/GARDASIL 9 lot number(s) that Plaintiff received but
rather, DEFENDANTS’ answers and responses will be based off information provided in Parts I and II of
the Plaintiff Fact Sheet (“PFS”) pursuant to DFSO. If Parts I and II of a PFS do not identify all variations
of a Plaintiff’s name(s) or address(es), the Plaintiff’s HEALTH CARE PROVIDER’s name(s), the
Plaintiff’s HEALTH CARE PROVIDER(s) address(es) or the GARDASIL/GARDASIL 9 lot number(s),
DEFENDANTS will be unable to provide responses to certain sections of the DFS and will respond as
such. This does not constitute a DFS deficiency. If a PFS is missing such information that renders
DEFENDANTS unable to provide responses to certain sections of the DFS, Plaintiffs reserve the right to
supplement the PFS with said information, or otherwise provide updated information to DEFENDANTS
via letter response by Plaintiff’s counsel that includes a verification of the amended responses signed by
the Plaintiff to DEFENDANTS’ counsel. Upon receipt of an updated PFS and notice that a Plaintiff is
requesting an updated DFS for that case, DEFENDANTS will have 30 days to produce additional
responsive information.
When producing DOCUMENTS that are responsive to a request in this DFS, DEFENDANTS will
only produce DOCUMENTS that are in their possession, custody, or control. The produced DOCUMENTS
shall be identified by Bates number and will be listed under the applicable DFS request(s). If the response
to any request herein is “no data found,” that response should be entered in the appropriate location(s). If
“no data found” is provided in response to a given section, this means that DEFENDANTS have conducted
a diligent, good faith search for the requested data, but the search has yielded no data. Such a finding does
not preclude later discovery into DEFENDANTS’ other sources of information or data.
Data output produced in response to the DFS may be responsive to more than one question
contained in the DFS. DEFENDANTS will identify each request in this DFS to which this data is responsive
and list the applicable Bates number(s). Data produced by DEFENDANTS in response to a request will be
deemed a complete response to that question based upon information in their possession at the time of the
service of this DFS.
Certain output from databases cannot be provided on a single page and cannot be manipulated and,
in such a situation, the data will be divided into multiple pages for production purposes. Nevertheless,
DEFENDANTS will strive in good faith to produce the data in a manner that makes it easy to review and
analyze.
In searching for and producing data responsive to this DFS, a database may return data that is non-
responsive or otherwise irrelevant to PLAINTIFF and/or a HEALTH CARE PROVIDER. An example of
such data is privacy information (e.g., social security numbers). If such data is redacted in the DFS package,
the DFS shall not be deemed deficient in this regard.
DEFINITIONS
As used herein, the below-listed terms are defined as follows:
“YOU,” “YOUR,” “YOURS” or “DEFENDANTS” means Defendants Merck & Co.,
Inc. and Merck Sharp & Dohme LLC, and the answers and responses to this DFS are by
and for those two entities only.
“GARDASIL” refers to the Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18)
Vaccine, Recombinant manufactured and marketed by Merck.
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“GARDASIL 9” refers to the Human Papillomavirus 9-valent (Types 6, 11, 16, 18, 31, 33,
45, 52, and 58) Vaccine, Recombinant manufactured and marketed by Merck.
“HEALTH CARE PROVIDER” means any physician, nurse or nurse practitioner or any
other persons who recommended, administered, provided information concerning and/or
discussed GARDASIL/GARDASIL 9 with PLAINTIFF as identified by name and address
in Sections I.B.1 and I.C.1-2 of the PFS, Part II in the case.
“DOCUMENTS” shall, consistent with Federal Rule of Civil Procedure 34(a)(1)(A), refer
to any “designated documents or electronically stored information – including writings,
drawings, graphs, charts, photographs, sound recordings, images, and other data or data
compilations – stored in any medium form which information can be obtained either
directly or, if necessary, after translation by the responding party into a reasonably usable
form.”
“PLAINTIFF” means the individual who was vaccinated with GARDASIL or
GARDASIL 9 and who is alleging personal injury as a result of receiving GARDASIL or
GARDASIL 9 vaccination in this case and whose name is listed below in Section I.
“RELEVANT TIME PERIOD” means, unless otherwise identified in a particular
request, the time period from 2006 to the Present (meaning the date the DFS collection
requests are submitted to DEFENDANTS).
I. CASE INFORMATION
This Defendant Fact Sheet pertains to the following case:
Case Caption: _____________________ v. Merck & Co., Inc., et al.
Civil Action No.: _____________________
Plaintiff Name: _____________________
Date this DFS was completed: _____________________
Date this DFS was supplemented, if applicable ___________
II. CONTACTS WITH PLAINTIFF’S HEALTH CARE PROVIDER(S)
In Sections I.B.1 and I.C.1-2 of the PFS, Part II in this case, PLAINTIFF is to identify the HEALTH
CARE PROVIDER(S) (by name(s) and address(es)) who recommended, administered, provided
information concerning, and/or discussed GARDASIL/GARDASIL 9 with PLAINTIFF (hereinafter
“HEALTH CARE PROVIDER”) For each HEALTH CARE PROVIDER identified in Sections I.B.1
and I.C.1-2 by name and address, please provide FOR THE RELEVANT TIME PERIOD the
following:
A. Identify contacts between YOUR professional representative(s) and the HEALTH CARE
PROVIDER(s) regarding GARDASIL/GARDASIL 9 identified in Sections I.B.1 and I.C.1-2 of
the PFS, Part II for the RELEVANT TIME PERIOD. YOUR response should include: each
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Professional Representative’s name, the HEALTH CARE PROVIDER’s name, the dates of
contact, and the available call/detail notes for the identified contacts.
B. For each professional representative, provide the name(s) of the professional
representative(s) supervisor/district manager(s).
C. If the professional representative(s) identified in response to questions II.A-B is no
longer an employee of DEFENDANTS, provide his/her last known address, if known.
D. Produce a copy of any Medical Information Request (“MIR”) or Professional
Information Request (“PIR”) related to GARDASIL/GARDASIL 9 that YOU sent in
the RELEVANT TIME PERIOD to the HEALTH CARE PROVIDER(s) identified by
name and address in PLAINTIFF’s PFS Sections I.B.1 and I.C.1-2.
E. If the HEALTH CARE PROVIDER(S) identified in PLAINTIFF’s PFS Sections I.B.1
and I.C.1-2 of the PFS, Part II contacted YOU in the RELEVANT TIME PERIOD by
any other means not already addressed in this Section concerning and/or requesting
information regarding GARDASIL/GARDASIL 9, its indications, potential side
effects and/or other risks, or to report adverse events, produce DOCUMENTS
reflecting these contacts, including YOUR response(s), if any.
III. CONSULTING WITH PLAINTIFF’S HEALTH CARE PROVIDER(S)
A. For each HEALTH CARE PROVIDER identified by name and address in Sections
I.B.1 and I.C.1-2 of the PFS, Part II, disclose whether he/she was ever retained by YOU
or compensated by YOU to be a clinical investigator, consultant, advisory board
member and/or a member of YOUR speaking program, if that retention related to
GARDASIL/GARDASIL 9, if available.
B. For each HEALTH CARE PROVIDER identified in Section III.A. above, provide the
date of any compensation, the amount of any compensation, the payee of any
compensation, the nature of the work performed for each compensation, if available,
and if it pertains to GARDASIL/GARDASIL 9.
C. Please identify and produce any and all consulting agreements/contracts and/or retainer
agreements/contracts entered into by YOU with the HEALTH CARE PROVIDER
identified in Sections III.A, if available and if it pertains to GARDASIL/GARDASIL
9.
IV. KEY OPINION LEADER INFORMATION
For each HEALTH CARE PROVIDER identified by name and address in PLAINTIFF’s PFS
Sections I.B.1 and I.C.1-2, disclose whether he/she was identified by YOU as a “Key Opinion
Leader” related to GARDASIL/GARDASIL 9 within the RELEVANT TIME PERIOD.
V. SALE TO HEALTH CARE PROVIDER(S) DIRECTLY
A. Did YOU sell, distribute, deliver, or otherwise provide
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GARDASIL/GARDASIL 9 to PLAINTIFF’s HEALTH CARE
PROVIDER(S) as identified by name and address in Sections I.B.1 and I.C.1-
2 of the PFS, Part II during the time period of three years preceding Plaintiff’s
first administration of GARDASIL/GARDASIL 9 through the Plaintiff’s last
administration of GARDASIL/GARDASIL 9?
____ Yes ____ No
B. If YOUR answer is “Yes” to Question A. above, please provide a list of all
deliveries or shipments of GARDASIL/GARDASIL 9 sold, distributed, or
otherwise provided to each of PLAINTIFF’S HEALTH CARE PROVIDER
as identified in the PFS for the time period spanning from three years prior to
Plaintiff’s first administration of GARDASIL/GARDASIL 9 through
Plaintiff’s last administration of GARDASIL/GARDASIL 9. Please include
the the date of shipment/distribution of GARDASIL/GARDASIL 9, the
amount of GARDASIL/GARDASIL 9 distributed on said date, and the
identification number for the batch shipped if available.
VI. GARDASIL/GARDASIL 9 CERTIFICATE(S) OF ANALYSIS(ES) AND FDA RELEASE
RECORD(S)
A. Produce a copy of the Certificate of Analysis(es) for the Gardasil/Gardasil 9 batch(es) for the
Lot Number(s) identified in Section I.B.1 in the Plaintiff’s PFS Part II.
B. Produce a copy of the FDA Release letter(s) for the Lot Number(s) identified in Section I.B.1
in the Plaintiff’s PFS Part II.
VII. ADDITIONAL INFORMATION WITHIN THE RELEVANT TIME PERIOD
A. For each HEALTH CARE PROVIDER identified in PLAINTIFF’s PFS Sections I.B.1 and
I.C.1-2 of the PFS, produce IMS data tracking that individual’s prescribing practices with
respect to GARDASIL/GARDASIL 9.
B. For each HEALTH CARE PROVIDER identified in PLAINTIFF’s PFS Sections I.B.1 and
I.C.1-2 of the PFS, identify and produce information of conferences, lectures, luncheons,
dinners or other similar meetings or events sponsored or co-sponsored by DEFENDANTS
related to GARDASIL/GARDASIL 9, HPV, Cervical Cancer or Vaccines that he/she attended,
if available.
C. Did YOU submit information and/or file DOCUMENTS relating to PLAINTIFF with the
Vaccine Adverse Event Reporting System (“VAERS”)?
☐ Yes ☐ No
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D. To the extent YOU have not already done so, please provide copies of the VAERS form(s)
submitted to FDA relating to PLAINTIFF that pre-date the filing of PLAINTIFF’s Complaint.
E. Please identify and produce information reflecting GARDASIL/GARDASIL 9-related
communications, if any, between YOU and PLAINTIFF or any person acting on behalf of
Plaintiff, if such communications are identified by DEFENDANTS search of the centralized
databases. DEFENDANTS search(es) will be limited to Plaintiff’s name(s) and address(es),
Plaintiff’s HEALTHCARE PROVIDER’S name(s) and address(es) and Plaintiff’s
GARDASIL/GARDASIL 9 lot number(s) as provided in the PFS.
F. Please identify and produce information reflecting GARDASIL/GARDASIL 9-related Dear
Doctor Letter(s), if any, that DEFENDANTS sent to any HEALTH CARE PROVIDER
identified in PLAINTIFF’s PFS Sections I.B.1 and I.C.1-2 of the PFS prior to the filing of
PLAINTIFF’s Complaint.
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CERTIFICATION
I am employed by ________________________, one of the DEFENDANTS in this litigation. I
am authorized by _________________________________________ [name of other DEFENDANTS] to
execute this certification on each corporation’s behalf. The foregoing answers were prepared with the
assistance of a number of individuals, including counsel for DEFENDANTS, upon whose advice and
information I relied. I declare under penalty of perjury subject to 28 U.S.C. § 1746 that all of the
information provided in this Defendant Fact Sheet is true and correct to the best of my knowledge upon
information and belief.
_______________________ __________________________ _____________________
Signature Print Name Date
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