Professional Documents
Culture Documents
Final Blank Boq Submitted
Final Blank Boq Submitted
PRELIMINARIES
SPECIAL NOTES
INDEX
SECTION NO. 1
PRELIMINARY PARTICULARS
1.1 PARTIES
For the purpose of the works which are under the control of
the consultants above, the
respective consultants shall be deemed to be invested with
the duties and be representatives
of the Architect.
1.2 SITE
The site of the works shall be used solely for the purpose of
executing and completing the
Contract to the satisfaction of the Architect.
"as directed" shall mean as directed by the Architect or any other consultant in the contract.
"BS" Shall mean the current British Standard Specification published by the British
Standards Institution, 2 Park Street, London W.1, England.
1.3.8 OVERTIME
The Contractor shall allow in their tender for any extra costs
for overtime working they
consider will be necessary in order to complete the works by
the contract Date of Completion.
1.4.1 WATER
All water shall be fresh, clean and pure, free from earthy
vegetable or organic matter, acid or
alkaline substance in solution or suspension.
The Contractor shall provide at their own risk and cost all
water for use in connection with the
Works (including the work of Sub-Contractors). The
Contractor shall provide at their own
expense all temporary distribution pipes, storage tanks,
meters, etc., and they shall clear
away same upon completion of the Works.
The Contractor shall provide at their own risk and cost all
artificial lighting and power for use
on the Works, including all Sub-Contractors' and Specialists'
requirements and including all
temporary connections, wiring, fittings, etc., and clearing
away on completion. The Contractor
shall pay all fees and obtain all permits in connection
therewith.
1.4.3 SAFETY
In particular there shall be proper provision of planked
footways and guard-rails to scaffolding,
etc.; protection against falling materials and tools and the Site
shall be kept tidy and clear of
dangerous rubbish.
1.5.1 GENERALLY
1.5..4 SAMPLES
1.7.2 TELEPHONE
1.7.3 SANITATION
All such plant, tools and scaffolding shall comply with all
regulations whether general or local, in
force throughout the period of the Contract and shall be
altered or adapted during the Contract
as may be necessary to comply with any amendments in or
additions to such regulations.
The Contractor must take such steps and exercise such care
and diligence as to minimize
nuisance from dust, noise or any other cause to the occupiers
of the existing and adjacent
property.
1.9 HOARDING
The Contractor shall enclose the site areas under which work
is carried out, with
1.80 meter high barbed wire fence comprising treated blue
gum poles at centres not
exceeding 3.0meters and 6No barbed wire strands at equal
spacing
The Contractor shall provide at their risk and cost all watching
and lighting as necessary to
safeguard the Works, plant and materials against damage and
theft.
1.11 SIGNBOARD
The actual net cost per unit will be adjusted within the Final
Account against the P.C. rate
stated.
1.13.1 PROTECTION
1.13.2 CLEANING
US$
Collection
TOTAL FOR SECTION 1: PRELIMINARIES AND GENERAL DESCRIPTIONS CARRIED TO GRAND SUMMARY US$
ITEM DESCRIPTION UNIT QTY RATE TOTAL
2.1.1 Clear site of all bushes and debris. Grab up roots and m2 1,600 -
burn the arisings -
-
Excavate over site 200 mm deep to remove vegetable soil
2.1.2 and cart away to spoil heap where directed on site m2 1,450 -
-
Anti-termite treatment -
2.1.6 -
Gladiator or equal and approved chemical anti-termite -
Formwork -
-
2.1.15 Formwork to sides of foundation columns m2 30 -
-
2.1.16 To the edges of ground slabs 100 - 200mm wide lm 304 -
-
2.1.17 To the sides of the ground beam 200mm wide lm 392 -
-
Reinforcement -
-
High Tensile mild steel reinforcement bars to BS 8666 in
Foundations -
-
2.1.18 8 mm diameter kg 1,050 -
-
2.1.20 12 mm diameter kg 112 -
-
Mesh reinforcement reference A142 weighing 2.22kg/m2 in
2.1.21 ground slabs m2 1,254 -
-
Walling -
2.1.22 400mm thick rubble stone foundation walling m2 400 -
-
Filling -
300mm thick approved hardcore filling compacted and laid
2.1.23 in layers not exceeding 150 mm thick m2 1,254 -
-
SUPER STRUCTURE -
-
2.2 ELEMENT NO. 2: REINFORCED CONCRETE -
-
Reinforced concrete class 25 in -
-
2.2.2 Columns m3 24 -
-
2.2.3 Ground beams and ring Beams m3 52 -
-
Formwork -
-
2.2.4 To sides of columns m2 290 -
-
2.2.5 To sides and soffits of beams m2 514 -
-
Reinforcement -
-
High Tensile mild steel reinforcement bars to BS 8666 in
Foundations -
-
2.2.6 8 mm diameter Kg 1,000 -
-
2.2.8 12 mm diameter Kg 1,950 -
-
2.2.9 16 mm diameter Kg 1,500 -
-
Structural Timbers
SAWN TREATED CYPRESS, Grade S50, pressure
impregnated
2.4.3 150 x 50 mm as trusses and rafters LM 750 -
Boarding
WROT CYPRESS, General Grade
45mm thick solid core flush door to B.S 459: parts faced both
sides with 6mm mahogany veneered plywood and lipped on
all edges in hardwood, including all planted moulding.
Complete with heavy duty hinges, brass locks, glass ventilight
and 100 mm mahogany frame -
2.6.1 50mm thick single door overall size 900x2400mm high No. 24 -
-
External Doors -
2.6.2
Ditto but double door overall size 1200mm * 2400mm high No. 9 -
-
2.6.3 Ditto but single door 900*2400mm high with 5 lever UNION
mortice lock No. 3 -
Painting
Fill uneven surfaces with stucco filler to approval and apply
two coats soft white external textured paint to: -
2.7.8 Plastered and rendered surfaces sm 2,656 -
Prepare and apply two undercoats of brilliant white emulsion
paint -
(RAL Code 9001) and two finishing coats of first quality
brilliant white -
Silk Vinyl emulsion paint (RAL Code 9001) to;- -
2.7.9 Plastered surfaces internally and externally sm 2,656 -
Ceiling Finish -
50 x 50 blandering on timber joists at 600mm centres
2.7.10 bothways sm 1,254 -
-
2.7.11 75 x 50 timber joists lm 1,000 -
Switches
2.7.17 5 Amps one gang one way switch No 24 -
HVAC
Supply, Deliver, Install, Test and Commission the following AC
indoor units
including with all accessories including all connections as
described.
PIPING
SANITARY INSTALLATIONS
Sanitary appliances complete with all the connections to
services,
PAGE
2 -
3 -
4 -
5 -
6 -
7 -
8 -
10 -
12 -
3.1.1 Clear site of all bushes and debris. Grab up roots and sm 180 -
burn the arisings -
-
3.1.8 Allow for keeping foundations free from water, mud, fallen Item Sum -
materials, etc.
-
Allow for planking and strutting as necessary to sides of
3.1.9 excavation Item Sum -
-
Concrete Works -
Plain concrete class 15 in: -
-
3.1.10 50mm blinding sm 33 -
-
Insitu concrete class 25/20 , vibrated and reinforced as
described, in:- -
-
3.1.11 Foundation Strip cm 10 -
-
3.1.12 Foundation columns cm 1 -
3.1.13 150 mm Ground floor slab sm 135 -
-
Page Total Carried Forward to Next Page -
ITEM DESCRIPTION UNIT QTY RATE TOTAL
Total Brought Forward from Previous Page -
Formwork -
-
3.1.14 Formwork to sides of foundation columns m2 6 -
-
3.1.15 To the edges of ground slabs 100 - 200mm wide lm 50 -
-
Reinforcement -
-
High Tensile mild steel reinforcement bars to BS 8666 in
Foundations -
-
3.1.16 8 mm diameter kg 70 -
-
3.1.17 10 mm diameter kg 130 -
-
3.1.18 12 mm diameter kg 15 -
-
Mesh reinforcement reference A142 weighing 2.22kg/m2 in
3.1.19 ground slabs m2 135 -
-
Anti-termite treatment -
-
3.1.20 Gladiator or equal and approved chemical anti-termite -
SUPER STRUCTURE -
-
3.2 ELEMENT NO. 2: REINFORCED CONCRETE -
-
3.2.1 Reinforced concrete class 25 in -
-
3.2.2 Columns m3 4 -
-
3.2.3 Beams m3 10 -
-
Formwork -
-
2.2.4 To sides of columns m2 34 -
-
2.2.5 To sides and soffits of beams m2 72 -
-
Reinforcement -
-
High Tensile mild steel reinforcement bars to BS 8666 in
Foundations -
-
2.2.6 8 mm diameter Kg 276 -
-
2.2.7 10 mm diameter Kg -
-
2.2.8 12 mm diameter Kg 90 -
-
2.2.9 16 mm diameter Kg 350 -
-
Structural Timbers
SAWN TREATED CYPRESS, Grade S50, pressure
impregnated
2.4.3 150 x 50 mm as trusses and rafters LM -
2.4.4 100 x 50 mm as trusses, trussed joists and struts LM 410 -
2.4.5 75x50mm purlins and joists and struts LM 291 -
2.4.6 150 x 50 mm as King post LM 32 -
2.4.7 Ditto, wall plate LM 32 -
2.4.8 25 x 150mm splice plates LM 32 -
2.4.9 25 x 200mm Ridge board LM 32 -
2.4.11 100 × 100 × 100 × 3mm thick angle cleat nailed to timber NO 50 -
Boarding
WROT CYPRESS, General Grade
2.4.13 25x50mm tongued and grooved boarding to eaves SM 20 -
2.4.14 25 x 250 mm Fascia board fixed to rafters LM 50 -
Painting and decorating
Knot, prime, stop and apply 3 coats polyurethane varnish to
2.4.16 eaves boarding SM 20 -
Ditto but 3 coats gloss oil paint to fascia board 200-300mm
2.4.17 girth LM 50 -
Rainwater disposal
2.4.22 Knot, prime, stop and apply 3 coats oil paint externally to:
Ceiling Finish -
50 x 50 blandering on timber joists at 600mm centres at
2.7.10 bothways sm 114 -
-
2.7.11 75 x 50 timber joists lm 120 -
Switches
HVAC
SANITARY INSTALLATIONS
Sanitary appliances complete with all the connections to
services,
waste, jointing to supply overflows and plugging and
scewing
to the floors. Where trade names are mentioned below, the
No.
2 -
3 -
4 -
5 -
6 -
7 -
8 -
10 -
12 -
3.1.1 Clear site of all bushes and debris. Grab up roots and sm 30 -
burn the arisings -
-
Formwork -
-
3.1.13 To the edges of ground slabs 100 - 200mm wide lm 20 -
-
Reinforcement -
-
High Tensile mild steel reinforcement bars to BS 8666 in
Foundations -
-
3.1.14 8 mm diameter kg 24 -
-
3.1.15 10 mm diameter kg 5 -
-
Mesh reinforcement reference A142 weighing
3.1.17 2.22kg/m2 in ground slabs m2 25 -
-
Anti-termite treatment -
-
Gladiator or equal and approved chemical anti-termite -
Walling -
3.1.18 400mm thick rubble stone foundation walling m 2
5 -
-
-
TOTAL CARRIED FORWARD TO SUMMARY -
ITEM DESCRIPTION UNIT QTY RATE TOTAL
SUPER STRUCTURE -
-
3.2 ELEMENT NO. 2: REINFORCED CONCRETE -
-
3.2.1 Reinforced concrete class 25 in -
-
-
3.2.3 Beams m3 2 -
-
Formwork -
3.2.4 To sides and soffits of beams m2 20 -
-
Reinforcement -
-
High Tensile mild steel reinforcement bars to BS 8666 in
Foundations -
-
3.2.5 8 mm diameter Kg 6 -
-
3.2.6 16 mm diameter Kg 126 -
-
Structural Timbers
SAWN TREATED CYPRESS, Grade S50, pressure
impregnated
3.4.3 150 x 50 mm as trusses and rafters LM -
3.4.4 100 x 50 mm as trusses, trussed joists and struts LM 180 -
3.4.5 75x50mm purlins and joists and struts LM 65 -
3.4.6 150 x 50 mm as King post LM 20 -
3.4.7 Ditto, wall plate LM 10 -
3.4.8 25 x 150mm splice plates LM 10 -
3.4.9 25 x 200mm Ridge board LM 10 -
3.4.10 100 × 100 × 100 × 3mm thick angle cleat nailed to timber NO 10 -
Boarding
WROT CYPRESS, General Grade
3.4.11 25x50mm tongued and grooved boarding to eaves SM 6 -
3.4.12 25 x 250 mm Fascia board fixed to rafters LM 10 -
Painting and decorating
Knot, prime, stop and apply 3 coats polyurethane varnish
3.4.12 to eaves boarding SM 6 -
Ditto but 3 coats gloss oil paint to fascia board 200-
3.4.13 300mm girth LM 10 -
Rainwater disposal
Ceiling Finish -
50 x 50 blandering on timber joists at 600mm centres at
3.7.6 bothways sm 114 -
3.7.7 75 x 50 timber joists lm 120 -
Switches
2 -
3 -
4 -
5 -
6 -
7 -
8 -
10 -
TOTAL FOR SECTION 5: CARRIED TO GRAND SUMMARY -
ITEM DESCRIPTION UNIT QTY RATE AMOUNT
5.1.1 Clear site of all bushes and debris. Grab up roots and m2 44 -
burn the arisings -
-
5.1.2 Load, wheel and cart deposit and spread surplus excavated -
5.2.3 Allow for keeping foundations free from water, mud, fallen -
materials, etc. LS 1 -
-
Disposal -
5.2.4 Return, fill and ram selected excavated material around -
foundations m3 16
5.2.5 Load, wheel and cart deposit and spread surplus -
excavated material where directed on site at a -
distance not exceeding 100 meters m3 24 -
-
Hardcore or other approved filling, as described -
Damp-proof membrane -
5.2.9 1000 gauge polythene or other equal and approved -
damp-proof membrane, laid over blinded hardcore -
(m.s) with 300mm side and end laps (measured -
nett-allow for laps) m2 44 -
-
Reference A142 mesh 200 x 200 mm , weight 2.22 kgs per -
square meter ( measured net - no allowance made for laps -
(inclunding bends, tying wire and distance blocks) -
SUB-STRUCTURE WALLING
5.5.13 Ditto but 3 coats gloss oil paint to fascia board 100-200mm girth LM 22 -
Rainwater disposal
150x150mm 24gauge galvanized mild steel box gutter with
5.5.14 galvanized steel brackets at 600mm centers LM 22 -
fixed to fascia board (ms)
Ditto, 100mm diameter down pipe fixed with brackets to wall at
5.5.15 1000mm maximum centers LM 18 -
5.5.16 Extra over ditto for 600mm swanneck projection NO 6 -
5.5.17 Ditto shoe NO 6 -
5.5.18 Knot, prime, stop and apply 3 coats oil paint externally to:
5.5.19 Timber fascia 200-300mm girth LM 22 -
5.5.20 Metal gutter SM 22 -
5.5.21 Prepare and apply bituminous paint to inside of gutter SM 22 -
Floor Finishes
Lighting Fittings
Switches
5.7.3 5 Amps two gang one way switch No 2 -
Socket outlets
5.8.4 10mm high tensile square twisted bars; cold worked; BS4461 KG 130 -
5.8.5 Supply and fix sawn formwork to sides of bottom slab L.M 13 -
5.8.8 Supply all materials and cast a 125mm thick vibrated reinforced C.M 2 -
concrete slab, mix1:2:4 or class 20/20. Top slab dimensions 2.5m
x 5.0m
5.8.9 10mm high tensile square twisted bars; cold worked; BS4461 KG 130 -
including bends, hooks, tying wire, distance blocks and spacers
for top slab; Y10@ 200mm c/c .
5.8.10 Supply and fix sawn formwork to sides of bottom slab L.M 13 -
5.8.11 Supply and fix sawn formwork beneath the slab S.M 13 -
Supply all materials and cast R.C. buffer beam, 100mm wide x
5.8.15 450mm deep, C.M 0 -
concrete class 20
WINDOWS
and throated and bedded and jointed in cement sand mortar No. 10 -
-
VENT BLOCKS -
-
5.9.4 2000mm x 800mm No. 50 -
-
-
DOORS -
45mm thick solid core flush door to B.S 459: parts faced both -
No.
1 -
2 -
3 -
4 -
5 -
6 -
7 -
9 -
10 -
Grand Total -
6.1.1 Clear site of all bushes and debris. Grab up roots and m2 12 -
burn the arisings
6.2.3 Allow for keeping foundations free from water, mud, fallen
materials, etc. LS 1 -
Disposal
6.2.4 Return, fill and ram selected excavated material around
foundations m3 16 -
6.2.5 Load, wheel and cart deposit and spread surplus
excavated material where directed on site at a
distance not exceeding 100 meters m3 16 -
Anti-termite treatment
Damp-proof membrane
BEAMS
6.3.2 Beams m3 2 -
SLABS
Reinforcement, as described:-[PROVISIONAL]
BEAMS
SUB-STRUCTURE WALLING
SUPER-STRUCTURE WALLING
6.5.10 100 × 100 × 100 × 3mm thick angle cleat nailed to timber NO 6 0
Boarding
6.5.11 WROT CYPRESS, Prime Grade
6.5.13 32 x 250 mm Fascia board fixed to rafters LM 9 0
Painting and decorating
Ditto but 3 coats gloss oil paint to fascia board 100-200mm
6.5.15 girth LM 9 0
4.69 Timber fascia 200-300mm girth LM 9 0
6.6.3 Skirtings;
100mm wide with rounded junction with wall finish and
coved junction
with floor finish m2 1 -
Wall Finish
Lighting Fittings
Switches
6.7.4 5 Amps two gang one way switch No 1 0
Socket outlets
6.8.5 Supply and fix sawn formwork to sides of bottom slab L.M 13 -
6.8.10 Supply and fix sawn formwork to sides of bottom slab L.M 13 -
6.8.11 Supply and fix sawn formwork beneath the slab S.M 13 -
Supply all materials and cast R.C. buffer beam, 100mm wide
6.8.15 x 450mm deep, concrete class 20 C.M 0 -
WINDOWS
VENT BLOCKS
DOORS
45mm thick solid core flush door to B.S 459: parts faced
both sides with 6mm mahogany veneered plywood and
lipped on all edges in hardwood, including all planted
moulding.
Complete with hinges and locks
No.
1 -
2 -
3 -
4 -
5 -
6 -
7 -
9 -
10 -
Grand Total -
Fencing -
SUMMARY
BARBED WIRE -
HESCO FENCE -
RAZOR WIRE -
TOTAL CARRIED TO MAIN SUMMARY -
ITEM DESCRIPTION UNIT QNTY RATE AMT US$
PROPOSED ……………………………………....
…….………………………………….. DISTRICT
Carried to Collection -
ELEMENT NO.2
EXCAVATION
8.4
Return fill and compact selected excavated CM 3.00 -
materials around foundations
Carried to Collection -
ITEM DESCRIPTION UNIT QNTY RATE AMT US$
ELEMENT NO.3
REINFORCED CONCRETE FRAME
In-situ concrete
Mass concrete( 1.3.6/38-38mm aggregate)
WALLING
Carried to Collection -
ELEMENT NO.5
FINISHES
Wall finishes
-
Plaster; 12mm thick 2 No. coatwork, generally to: - -
9mm first coat of cement sand (1:6); 3mm
second coat of cement and lime putty (1:10);
steel trowelled toconcrete or blockwork base
Floor finishes
Beds or Backings
STEEL LADDER
Carried to Collection -
ELEMENT NO.7
LIGHTING
Carried to Collection -
MAIN SUMMARY
1 1/8 -
2 2/8 -
3 3/8 -
4 4/8 -
5 5/8 -
6 6/8 -
8 8/8 -
Total -
PROPOSED ……………………………………....
…….………………………………….. DISTRICT
9 SECTION 9 : GATES
Backfill
9.4 Return fill and compact selected excavated materials
around foundations CM 1.50 -
BEAMS
COLUMNS
GROUND BEAM
9.11 Y12 (Nominal Diameter 12mm) bars as main bars,
Cross-Sectional Area (113mm2), Mass per unit length (0.888kg/m Kg 8.88 -
COLUMNS
COLUMN BASES
STARTER COLUMNS
COLUMNS
6m HIGH COLUMNS
Beams
ELEMENT 4: WALLING
SUBSTRUCTURE WALLING
ELEMENT 5: FINISHES
ELEMENT 6: GATES
9.22 Supply and fix double leaf steel gate size 5000x 2100mm high with
small pedestrian door made from 3mm thick steel plate welded on
both sides of the frame. Frame as follows: 75x50x3mm thick
RHS external members and 25mm SHS 3mm thick secondary
members, fixed onto the concrete columns using heavy duty steel
pin hinges; with all fastening accessories including all cutting welding,
grinding and priming with one coat of grey oxide before fixing.
The gate should also have peep holes of not more that 25mm dia
with a slilding door. It should also have 2 locking mechanisms,
top and bottom. No. 1 -
ELEMENT NO.1
STEEL FRAME
9.23 Supply and Provide 5'' (12.5cm) dia. Pipe for 9m long
with three layers that is bonded by 2'' (50mm) dia.
Pipe as Per drawing. LM 69 -
FINISHES
11.3 150mm thick vibrated reinforced concrete for bottom C.M 1.88 -
slab (concrete class 20)
11.5 Supply and fix sawn formwork to sides of bottom slab L.M 12.50 -
11.10 Supply and fix sawn formwork to sides of bottom slab L.M 12.50 -
11.11 Supply and fix sawn formwork beneath the slab S.M 12.50 -
11.20 Backfill with well packed approved hardcore to 2m depth C.M 3.50 -
SITE PREPARATION
SUBSTRUCTURES (PROVISIONAL)
Disposal
Anti-termite treatment
11.7 Gladiator or equal and approved chemical anti-termite
11.11 Lintols CM 0 -
Reinforcement, as described:-[PROVISIONAL]
FOOTING
LINTOLS
11.2 To edge of steps and slabs over 75mm but not exceeding
150mm high LM 24 -
ELEMENT NO. 3
WALLING
ELEMENT NO. 5
FINISHES
Floor Finishes
Cement and sand (1:3) screeds, backings, beds etc
DOORS
No.
No.
Trench excavation
Cabling
11.47 Supply, install and connect 1x3x95+1x50 Sq. mm
PROPOSED ……………………………………....
…….………………………………….. DISTRICT
13 SECTION 13: SOLAR STREETLIGHTS
13.1.1 Clear site of all bushes and debris. Grab up roots and m2 30 -
burn the arisings -
-
13.1.2 Load, wheel and cart deposit and spread surplus excavated -
material where directed on site at a distance not
exceeding -
100 meters Item 1 -
13.2.6 Allow for keeping foundations free from water, mud, fallen -
materials, etc. LS 1 -
-
Disposal -
-
BEAMS
GROUND BEAM
6m HIGH COLUMNS
13.3.23 Y16 (Nominal Diameter 16mm) bars as main bars,
Cross-Sectional Area (201mm2), Mass per unit length
(1.579kg/m) Kg 171 -
-
13.3.24 R8 (Nominal Diameter 8mm) bars as rings, -
Cross-Sectional Area (50.3mm2), Mass per unit length
(0.395kg/m) Kg 151 -
-
ROOF SLAB -
13.4 WALLS -
-
13.6.2 Supply and install 50mm diameter inlet pipe 800mm long No. 1 -
-
13.6.3 Supply and install 50mm diameter draw off pipe Ditto No. 1 -
-
13.6.4 Supply and install 50mm diameter overflow pipe Ditto No. 1 -
-
13.6.5 Supply and install 75mm diameter scour pipe Ditto No. 1 -
-
Supply and install 20mm diameter brass gate valve with
13.6.6 wheel and head No. 1 -
-
13.6.7 Supply and install 20mm diameter stop corks No. 1 -
-
DOOR
SUMMARY
ELEMENT NO. 1
Solar Streetlights
14.1 Clear site of all bushes and debris. Grab up roots and sm 350 -
burn the arisings -
-
Structural Timbers
SAWN TREATED CYPRESS, Grade S50, pressure
impregnated
14.5 150 x 50 mm as trusses and rafters LM 150 -
14.12 100 × 100 × 100 × 3mm thick angle cleat nailed to timber NO 15 -
Boarding
14.13 25 x 250 mm Fascia board fixed to rafters LM 85 -
Painting and decorating
Ditto but 3 coats gloss oil paint to fascia board 200-
14.14 300mm girth LM 85 -
ROOFING TOTAL CARRIED TO MAIN SUMMARY -
ITEM NO. DESCRIPTION PAGE
GRAND SUMMARY
SECTION NO. 1 PRELIMINARIES AND GENERAL DESCRIPTIONS -
SIGNED:
(CONTRACTOR)
Address:
Tel No:
Date:
SIGNED:
(EMPLOYER )
Address:
Tel No:
Date: