       6IDesILaytags R 6 
10209820011DSHS ASDState of Washington
10_209.itp                                                                                                                                                                                                                                                                                                                                                                                                                                                                            l                                                                                                                                                                                                                                                                                                           "  F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
      6            R   
   4         	   	P   f      0          r    h   
  `   *   >  P         t                                                              &    ,    2    8    >    D    J    P    V    \    b    h    n    t    z                            6        ( P9serdict begin /11x17        6    N         Submit             t b        6         }{statusdict /setpageparams            H        H H    @RG(    H H    @    d       '                     `                                  H  4             6  4        6  4  T     v exch scale pop pop xl}bdf/o        6    Z                -1 rol       N  	  `  8      <                            @fffffff@             `	 C""BgHn/. Hn0<N j   @(0# p n C"" n C""BgHn.1&@  XX     jdV      XX        d        '               |N?           d           H         6  	P  B                        se mov        V  
     "                               ҅hM        V  
     "                                 propalis             *       propalis  B   	Helvetica@@ G@
 _ D nT    @               Geneva ?~D       @E qÀp pCE k    pEr                    $    
1020982001                     1                              DSHS ASD                       State of Washington          
10_209.itp    -@        J    -1 rol            &  6         	Signature   Version      Graphics         <TiffList       TPageList     ZHeader% ޾  `	FieldList ޾  lLayoutProps	B    	Blue Keys  ʀ  f	Form Info  Kl    $ConvertDataVers  ~DesPathInfo      xCurrSelection    6Con         6  
          oveto}bdf/rm{it rmovet        6  0  f        76069503821609045 Ver        6  f  ~        @      @                 6    x   this   ҄҄            pr    0   6              iv translate newpath 0             By      @`0 @                                    l 
                           Pp                   PROGRAM NAME                                              
                 
    ,  Arial          (  (PROGRAM NAME                  @`p             I   CHILDREN'S ADMINISTRATIONDOMESTIC VIOLENCE PERPETRATOR TREATMENT PROGRAM      	                 s @      s        @        
                           
  s @ ,  Arial          ( * CHILDREN'S ADMINISTRATION                   ( 3 /DOMESTIC VIOLENCE PERPETRATOR TREATMENT PROGRAM                /p/                 DSHS 10-209 (08/2001)                    =       `              %   APPLICATION FOR PROGRAM CERTIFICATION       
              
     @`p @                                    l 
                    e       Pp`                  DIRECTOR'S NAME                       `           `          
                 
  ` ,  Arial          (
 (DIRECTOR'S NAME                 0@# @                               @     l 
                          @A#                  TELEPHONE NUMBER                       D          D           
  `                 
  D ,  Arial          ( TELEPHONE NUMBER                  *`+p#    8              *	+p              5   FOR DEPARTMENT OF SOCIAL AND HEALTH SERVICES USE ONLY          
        
 F  
    p"`                  > 
The application fee is $100.00.  Only those Staff Statement of Qualifications forms (DSHS 10-210) submitted with this application are accepted under this fee; the Department may charge an additional fee for adding documents.         	               	              	             R - 0     -   R  0           
  D                 
 R - 0 ,  Arial          ( b 7The application fee is           ( b $100.00           ( b D.  Only those Staff Statement of Qualifications forms (DSHS 10-210)             ( l 7esubmitted with this application are accepted under this fee; the Department may charge an additional            ( v 7fee for adding documents.                  P@               3   * 
 The enclosed forms must be filled out completely.        	            2  	               A   _N          A  N   _        
                 
 A   _N ,  Arial         ( Q *2 The enclosed forms must be filled out completely.            ( QD                 p	"p                  Programs that do not meet the standards for certification will be notified by the Department as stated in WAC 388-60-0465 and WAC 388-60-0485.       	            .. u - 1    . -   u  1           
 A   _N                 
 u - 1 ,  Arial          (  7jPrograms that do not meet the standards for certification will be notified by the Department as stated in             (  7$WAC 388-60-0465 and WAC 388-60-0485.                 (`*@@                               )@     l 
                            (p)A                  DIRECTOR'S SIGNATURE                                          
 u - 1                 
  ,  Arial          ( (DIRECTOR'S SIGNATURE                  (P*@#@                               )@     l 
                            (`)A#                  DATE                     D         D          
                  
D ,  Arial          (DATE                  !                  Our program complies with the following sections of Washington Administrative Code (WAC) 388-60(If yes, check all applicable boxes.)       	            $$ $%    $ $    %          
D                 
 $% ,  Arial          ( .`Our program complies with the following sections of Washington Administrative Code (WAC) 388-60            ( .%(If yes, check all applicable boxes.)                 p @                                    l 
                         `                 WAC 388-60-0045       	             b     Z 	       `0 @                                    l 
                         `                  WAC 388-60-0075       	             b     Z 	      @   0 @                                    l 
                         P                    WAC 388-60-0065 thru 0305       	             b      	          0 @                                    l 
                                             WAC 388-60-0315 thru 0395       	             b      	        `              a    Treatment focusTreatment modalityProgram policies and proceduresTreatment staff qualifications       	            ((     (               
                 
  ,  Arial          ( Treatment focus            ( Treatment modality           (  Program policies and procedures            (
 Treatment staff qualifications                   !0 @                                    l 
                          !                  WAC 388-60-0405       	             b     Z 	      "P #00 @                                    l 
                         "`#0                  WAC 388-60-0455       	             b     Z 	      ! "`0 @                                    l 
                         !"`                  WAC 388-60-0425       	             b     Z 	        # "                   Orientation and continuing professional education requirementsKnowledge of law and justice system practicesCooperation with domestic violence victim programs       	            RR <9    R     9  <        
                 
 <9 ,  Arial          ( ?Orientation and continuing professional education requirements           (" .Knowledge of law and justice system practices            (. 2Cooperation with domestic violence victim programs                 p #               ~    
The program must submit a completed and signed Staff Statement of Qualifications (DSHS 10-210) for each person listed above.         	             H;     H    ;          
 <9                 
 H; ,  Arial          ( R_The program must submit a completed and signed Staff Statement of Qualifications (DSHS 10-210)            ( Rfor each person listed above.                  @0# @                                    l 
                          P@#              
    FAX NUMBER                       D          D           
                 
  D ,  Arial          ( 
FAX NUMBER                  @                 @          @p# @    	                                l 
                           P#                  E-MAIL CONTACT                      ND     N     D          
  D                 
 ND ,  Arial          (
YE-MAIL CONTACT                  `@p @                               @     l 
                           pA`                  MAILING ADDRESS                                                
 ND                 
     ,  Arial          (  (MAILING ADDRESS                 p@p @                               @     l 
                           A`                  CITY                        `           `           
                     
   ` ,  Arial          (  CITY                  p@  @                               @     l 
                           A                  STATE                      N      N                
                 
 N  ,  Arial          ( YSTATE                  @0 @                               @     l 
                          A                   ZIP CODE                      w      w                
 N                  
 w  ,  Arial          ( ZIP CODE                  `#    C              	`               (   LIST NAMES OF ALL DIRECT TREATMENT STAFF          
        
    
    `#      
                            @                                  pA#                        	             T            @`  @                              @     n 
                          PpA                NAME      	             H        @  @                              @     n 
                          PA                STAFF LEVEL REQUESTED      	             H g       @ p @ C   C                          @     n 
                         PA `                APPROVED      	             H +       @ p# @ C   C                          @     n 
                         P A#                DATE      	             H        +p`-#    C              &P(#                 I certify under penalty of perjury that the information provided in this application for certification/re-certification is true and correct.  I understand that any material misrepresentation or misstatement of fact may result in sanctions, including the loss of program certification.       	           [ D       [  D          
                 
[ D ,  Arial         (n (hI certify under penalty of perjury that the information provided in this application for certification/         ({ ([re-certification is true and correct.  I understand that any material misrepresentation or         ( (Zmisstatement of fact may result in sanctions, including the loss of program certification.                 `(#                  @#    C              P#                   FOR DSHS USE ONLY       	              Y      (*@P@                               )@     l 
                            ()A@                  PRINT DIRECTOR'S NAME                                          
                 
  ,  Arial          (PRINT DIRECTOR'S NAME                 -`/@@ @ C   C                           .@     l 
                            -p.A0                  DSHS STAFF SIGNATURE                                         
                  
  ,  Arial         ( (DSHS STAFF SIGNATURE                  -@/@# @ C   C                           .@     l 
                            -P.A#                  DATE                    D         D          
                  
D ,  Arial         (DATE                  -0-     C            MONTH    DAY   YEAR                    @      - -"      C            MONTH    DAY   YEAR                    @      , -`      C            to       	              	     +
- 0H  C   C                             ,  @   l 
                                           Title                         - P-     C            MONTH    DAY   YEAR                    @      ,-`     C            Certified from       	             N 	     ,`-`
     C            Check deposited on:       	             r 	     0`@#                  + -p H  C   C                             ,  @   l 
                                           Title                         + - "p H  C   C                             ,  @   l 
                                           Title                         #%P"                  Our program consents to on-site review of program files for the purpose of determining WAC compliance by DSHS staff responsible for certification of domestic violence perpetrator treatment programs.        	            ff1 $_7    f $  1  7  _        
                 
1 $_7 ,  Arial          (D .fOur program consents to on-site review of program files for the purpose of determining WAC compliance             (Q .aby DSHS staff responsible for certification of domestic violence perpetrator treatment programs.                 %@p&   @                               @     l 
                        %PP&                   Yes       	             b      	      %@ & " @                               !     l 
                        %P!& "                 No       	             b      	      @                  NOTE:       	              	     P               '    Incomplete forms will not be accepted.       	                	     	
                    
Mail completed application to:       	               %        %                 
                 
  %   ,  Arial         (  /Mail completed application to:                 
 0!                   
Department of Social And Health Services (DSHS)Children's AdministrationDomestic Violence Perpetrator Treatment Program CertificationPO Box 45710Olympia, WA  98504-5710       	                                    
  %                   
    ,  Arial          (  0Department of Social And Health Services (DSHS)            (  Children's Administration            (  >Domestic Violence Perpetrator Treatment Program Certification            (  PO Box 45710           (  Olympia, WA  98504-5710                                                           1 409.953 C266.2519 410.6872 265.7116 410.626 264.3455 412.7572 C262.1333 416.2244 263.7339 424.9432 271.6855 424.8514 C271.6855 424.8514 279.4332 424.3823 279.525 416.9484 C279.5964 410.8707 275.5594 410.5648 275.1006 408.9842 C275.1006 408.9842 275.3453 408.3316 276.171 408.3316 C276.9866 408.3316 281.1153 408.3316 281.1153 408.3316 C281.1153 408.3316 282.8178 412.2984 287.181 412.4513 C291.5136 412.6043 293.8685 409.3207 293.8583 405.67 C293.8379 401.9785 290.2291 400.0716 289.9845 399.6025 C289.9845 399.6025 290.1374 399.0213 291.5544 399.0213 C292.9714 399.0213 304.1037 399.0213 304.1037 399.0213 C304.1037 399.0213 305.1639 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@    d    m             Black     _   DIVISION OF CHILDREN AND FAMILY SERVICES (DCFS)DOMESTIC VIOLENCE PERPETRATOR TREATMENT PROGRAM                    @/@#    d                Red          /`  /    d                 Black         DSHS 10-209 (01/94)                  	p0    d                  Black     %   APPLICATION FOR PROGRAM CERTIFICATION       
            @@    d    "             BlackCell2      d              d               dx     d d     l  KP P                    e                          P    d    @             Black           DIRECTOR'S NAME                       p@    d    9             Black      %    
Forward the completed application to:           	        @#    d    "             BlackCell1  2 N   d              d               dx     d d     l  KP P                                              #    d                  Black           TELEPHONE NUMBER                       > @B#    d                  Red@ @@#      @@                     BlackCell3  2 N                              dx     d d     l  KP P                                              P    d                  Black           MAILING ADDRESS                       `@#                     BlackCell16 2 N                              dx     d d     l  KP P                                             p#    d                  Black           ZIP CODE                       @`                     BlackCell17 2 N                              dx     d d     l  KP P                                              `    d                  Black           STATE                       @                     BlackCell21 2 N                              dx     d d     l  KP P                                                 d                  Black           CITY                       &@ @' #    d                 Red          &p&    d                 Black      ,   FOR DEPARTMENT OF SOCIAL AND HEALTH USE ONLY                  ( p(    d                   Black         Check deposited on:           	        (~(@    d                  Red((@     )`P*@    d      "             BlackCell27  4   8                 d                 d      d     l 	 KP P                                           )p0*`    d                  Black          Certified from           	          )0*    d                  Red* 0*      )*@    d                 Black         to           	        )*    d                  Red* *      * *     d                   Black         MONTH    DAY   YEAR                   * 0*    d                  Black         MONTH    DAY   YEAR                   ,`P-@    d      "             BlackCell4  9 N                d                 d      d     l 	 KP P                                           ,p0-`    d                 Black          Sent to board for review:           	          ,-    d                  Red- -      - 	-`    d                  Black         MONTH    DAY   YEAR                   - . @    d      "             BlackCell5  9 N  	              d                 d     d     l 	 KP P                                           -0. @    d                  Black          Approved           	          -.@    d                    BlackCell6  9 N  
              d                 d     d     l 	 KP P                                           -.@    d                  Black          Disapproved           	          -	.    d                    BlackCell7  9 N                d                 d
     d     l 	 KP P                                           -
.    d                  Black          Remedial suggestions:           	           "    d    9             Black           
The application fee is $45.00.  Only those Statements of Qualifications from Staff and Volunteers, DSHS 10-210, submitted with this form are accepted under one fee; any others are considered as a separate program and another fee will be charged.             	         
`#P    d                  Black      4   R 
The enclosed forms must be filled out completely.  Incomplete applications, Information Requests (DSHS 10-211), and/or Statements of Qualifications for Staff and Volunteers (DSHS 10-210) will be returned.  Three references are required.  Please use the Information Request, DSHS 10-211), for your references.          	         0     	               	              	        pP"    d                  Black      7    
Applicant programs which meet WAC standards will be certified as soon as processed.  Programs which do not meet standards will be notified by the Department of Social and Health Services; and, on program request, the application may be reviewed by the department's standards board at the next scheduled meeting.           	        (p)     d                  Black         MONTH    DAY   YEAR                   "$p#    d                   Black           	I hereby certify that the information provided in this application is true and correct and that the Domestic Violence Perpetrators Treatment Program of which I am director meets or exceeds the standards listed in WAC 388-60.          	        $ @&@0    d    "             BlackCell11 7 T~   d              d               d%x     d d     l  KP P                                             $ P%0    d                  Black           DIRECTOR'S SIGNATURE                       $0&@#    d                  BlackCell12 ? T~   d              d               d%x     d d     l  KP P                                             $@%#    d                  Black           DATE                       ". @"2#    d                  Red"0 @"0#      @ #    d                  Black                  d                d                   p  d   d            gHn                                                     d                   Black         Title                       @      d                   BlackCell15. /N  d                d                  ^  d /-  d d     n BP n                                            P	0    d                  Black         Title                             d                    BlackCell18. /N  d                d                     d ^  d d     n BP n                                           	@    d                  Black         Title                        #    d                    BlackCell19. /N  d                d                   d   d d     n BP n                                           #    d                  Black         Title                       p! `    d    9             Black          
DOMESTIC VIOLENCE PERPETRATOR TREATMENT PROGRAM CERTIFICATIONDEPARTMENT OF SOCIAL AND HEALTH SERVICESDIVISION OF CHILDREN AND FAMILY SERVICESPO BOX 45710OLYMPIA WA  98504-5710           	        `    d                 Black      k   Check each of the following indicating program compliance with Washington Administrative Code (WAC) 388-60.           	        P    d      1             BlackCell8  9 T~                d                 d      d     l 	 KP P                                           0    d                   Black          WAC 388-60-120           	          `P@    d                    BlackCell9  9 T~                d                 d      d     l 	 KP P                                           p0`    d                  Black          WAC 388-60-130           	           P     d                    BlackCell13 9 T~                d                 d      d     l 	 KP P                                           00     d                  Black          WAC 388-60-140           	          P    d                    BlackCell14 9 T~                d                 d      d     l 	 KP P                                           0    d                  Black          WAC 388-60-150           	          p    d    9             Black      a    Treatment focusTreatment modalityProgram policies and proceduresTreatment staff qualifications           	            d      "             BlackCell20 D T~                d                 dP     d     l 	 KP P                                           `    d                  Black          WAC 388-60-160           	                d                    BlackCell22 D T~                d                 dP     d     l 	 KP P                                           0`     d                  Black          WAC 388-60-170           	              d                    BlackCell23 D T~                d                 dP     d     l 	 KP P                                           `    d                  Black          WAC 388-60-180           	          #`    d    9             Black          Orientation and continuing professional education requirementsCooperation with domestic violence victim programsKnowledge of law and justice system practices           	        *P+    d      "             BlackCell24 6 2                d                 d      d     l 	 KP P                                           *0+    d                  Black       *   Pending; need more information.  Returned:           	          +~+     d                  Red++      + , p    d                   Black         MONTH    DAY   YEAR                   
"    d                  Black       ]   Indicate the number of individuals submitting statements of qualifications from this program:           	            d                  Red     @P    d                 Black         Trainees           	        	`p    d                  Red	`p     @P    d                 Black         Practicing staff or volunteers           	        P`    d                  RedP`     @     d                 Black         Supervisors           	        #0    d                  Black          
Each of the individuals you have indicated above must complete a Statement of Qualifications for Volunteers and Staff, DSHS 10-210.  These forms may be photocopied for additional applicants.  If necessary, additional documentation and pages may  be included to fully answer the questions; however, resumes are not acceptable.List the names of the individuals you have indicated above:           	        @#    d    "             BlackCell25 ? T~   d              d               d     d d     l  KP P                                             P #    d                  Black       "    LENGTH OF TIME PROGRAM HAS EXISTED                       TH OF TIME PROGRAM HAS EXISTED                              BlackCell20  .J "  d                d                 ^  d /-  d d     n BP n                                            P    d    #             Black         DATE                             d                    BlackCell22+H t   d                d                 ^  d /-  d d     n BP n                                                d                  Black      !   ORGANIZATION PROVIDING EXPERIENCE                         #    d                    BlackCell23+H t   d                d                  d 0.  d d     n BP n                       F  >      .                            ;      -           #####;#####-####              (    )      -           (###) ###-####   (000) 000-0000       @@                  X       
              g  
        @@                        @@                     @@              @@                       @    @@                    g          S S     S  ڼ`ɉ    <    `/  S      <          `/ RA, gS "        ` S `/ p @    
   
   ޮ  <S    ݮ  | S `/ S $    `/  S (A "    `/  vS "    @/  8A ݮ  "                A :               /       " :  A "           @@@@                                _     l                               @@                 X                                  @@                                                                            @@                X                                      @@@@                               n      n                                @@                X                                2        L                     h  "     3     Submit                                     h  l                                -     4 e          ;          B     I     P     W     ^     e     l     s    z                                                  !     '   Cell2Cell1Cell10Cell11Cell12Cell8Cell9Cell13Cell14Cell20Cell22Cell23Cell25Cell28Cell29Cell30Cell31Cell32Cell34Cell35Cell36Cell37Cell21Cell39Cell40Cell41Cell42Cell43Cell44Cell45      Cell47       Cell48       Cell49       Cell50       Cell51       Cell52       Cell35    Cell36    Cell37    Cell38    Cell39       Cell40       Cell41       Cell42       Cell53       Cell54       Cell55       Cell56       Cell57    Cell58    Cell63    Cell64    Cell59       Cell60       Cell61       Cell62    Cell65    Cell66       Cell67       Cell68       Cell1    Cell3    Cell16    Cell17    Cell21    Cell27    Cell4    Cell5    Cell6    Cell7        Cell67       Cell68                                              
  
      
         4       
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                     H   H            Ff                                                                                                                                             
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                     H   H            Ff               j                                                                                            
                     H   H            Ff               d                                                                                         
                     H   H            Ff               m                                                                                                
                     H   H            Ff                                                                                        
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                     H   H            Ff                                                         
                     H   H            Ff                                                   
                     H   H            Ff                                                                   
                     H   H            Ff                                                                      
 ~                    H   H            Ff          ~                                                
 }   ~                 H   H            Ff          }   ~   z                             
 |   }                 H   H            Ff          |   }   z                             
 {   |                 H   H            Ff          {   |   z                             
 z   {                 H   H            Ff          z   {   z                                
 y   z                 H   H            Ff          y   z   k                           
 x   y                 H   H            Ff          x   y   \                    
 w   x                 H   H            Ff          w   x   \                    
 v   w                 H   H            Ff          v   w   \                    
 u   v                 H   H            Ff          u   v   \                    
 t   u                 H   H            Ff          t   u   \                    
 s   t                 H   H            Ff          s   t   \                    
 r   s                 H   H            Ff          r   s   \                    
 q   r                 H   H            Ff          q   r   \                    
 p   q                 H   H            Ff          p   q   \                    
 o   p                 H   H            Ff          o   p   \                    
 n   o                 H   H            Ff          n   o   \                    
 m   n                 H   H            Ff          m   n   \                    
 l   m                 H   H            Ff          l   m   \                    
 k   l                 H   H            Ff          k   l   \                    
 j   k                 H   H            Ff          j   k   \                    
 i   j                 H   H            Ff          i   j   b                       
 h   i                 H   H            Ff          h   i   b                       
 g   h                 H   H            Ff          g   h   q                              
 f   g                 H   H            Ff          f   g   q                              
 e   f                 H   H            Ff          e   f   q                              
 d   e                 H   H            Ff          d   e   e                           
 c   d                 H   H            Ff          c   d                                                
 b   c                 H   H            Ff          b   c  X                                                                                                  
 a   b                 H   H            Ff          a   b                                                                                                                 
 `   a                 H   H            Ff          `   a                                                                                                                                              
 _   `                 H   H            Ff          _   `                                                                                                                                                    
 ^   _                 H   H            Ff          ^   _                                                                                                                                                    
 ]   ^                 H   H            Ff          ]   ^                                                                                                                                                 
 \   ]                 H   H            Ff          \   ]                                                                                                                                               
 [   \                 H   H            Ff          [   \                                                                                                                                         
 Z   [                 H   H            Ff          Z   [                                                                                                                             
 Y   Z                 H   H            Ff          Y   Z  d                                                                                                                  
 X   Y                 H   H            Ff          X   Y  _                                                                                                               
 W   X                 H   H            Ff          W   X  e                                                                                                                     
 V   W                 H   H            Ff          V   W  \                                                                                                        
 U   V                 H   H            Ff          U   V  \                                                                                                        
 T   U                 H   H            Ff          T   U                                                                                                                               
 S   T                 H   H            Ff          S   T  w                                                                                                               
 R   S                 H   H            Ff          R   S                                                                          
 Q   R                 H   H            Ff          Q   R  7                                                                                        
 P   Q                 H   H            Ff          P   Q                                                                          
 O   P                 H   H            Ff          O   P                                                         
 N   O                 H   H            Ff          N   O                                                            
 M   N                 H   H            Ff          M   N                                                            
 L   M                 H   H            Ff          L   M                                                           
 K   L                 H   H            Ff          K   L                                                      
 J   K                 H   H            Ff          J   K   t                             
 I   J                 H   H            Ff          I   J   n                          
 H   I                 H   H            Ff          H   I   8           
 G   H                 H   H            Ff          G   H   8           
 F   G                 H   H            Ff          F   G   8           
 E   F                 H   H            Ff          E   F   8           
 D   E                 H   H            Ff          D   E   8           
 C   D                 H   H            Ff          C   D   2        
 B   C                 H   H            Ff          B   C   2        
 A   B                 H   H            Ff          A   B   2        
 @   A                 H   H            Ff          @   A   2        
 ?   @                 H   H            Ff          ?   @   8           
 >   ?                 H   H            Ff          >   ?   8           
 =   >                 H   H            Ff          =   >   8           
 <   =                 H   H            Ff          <   =   8           
 ;   <                 H   H            Ff          ;   <   8           
 :   ;                 H   H            Ff          :   ;   8           
 9   :                 H   H            Ff          9   :   8           
 8   9                 H   H            Ff          8   9   8           
 7   8                 H   H            Ff          7   8   8           
 6   7                 H   H            Ff          6   7   8           
 5   6                 H   H            Ff          5   6   8           
 4   5                 H   H            Ff          4   5   8           
 3   4                 H   H            Ff          3   4   8           
 2   3                 H   H            Ff          2   3   8           
 1   2                 H   H            Ff          1   2   H              
 0   1                 H   H            Ff          0   1   H              
 /   0                 H   H            Ff          /   0   H              
 .   /                 H   H            Ff          .   /   H              
 -   .                 H   H            Ff          -   .   H              
 ,   -                 H   H            Ff          ,   -   H              
 +   ,                 H   H            Ff          +   ,   H              
 *   +                 H   H            Ff          *   +   H              
 )   *                 H   H            Ff          )   *   H              
 (   )                 H   H            Ff          (   )   H              
 '   (                 H   H            Ff          '   (   H              
 &   '                 H   H            Ff          &   '   H              
 %   &                 H   H            Ff          %   &   H              
 $   %                 H   H            Ff          $   %   H              
 #   $                 H   H            Ff          #   $   H              
 "   #                 H   H            Ff          "   #   H              
 !   "                 H   H            Ff          !   "   H              
     !                 H   H            Ff              !   H              
                      H   H            Ff                 H              
                     H   H            Ff                H              
                     H   H            Ff                H              
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                <           
                     H   H            Ff                2        
                     H   H            Ff                2        
                     H   H            Ff                2        
                     H   H            Ff                2        
                     H   H            Ff                2        
                     H   H            Ff                2        
                     H   H            Ff                &     
 
                    H   H            Ff          
      &     
 	   
                 H   H            Ff          	   
   &     
    	                 H   H            Ff             	   &     
                     H   H            Ff                &     
                     H   H            Ff                &     
                     H   H            Ff                &     
                     H   H            Ff                &     
                     H   H            Ff                &     
                     H   H            Ff                &     
                     H   H            Ff                &     
                      H   H            Ff                           N  t     3     Submit                             `  *      XX     jdV      XX        d        '               |N?           d                              b        @      4@        @            "                     4҅h\\҅h\\\\݃PP\                   propalis                        propalis  N   propalis  H   propalis  B   porpsila     porpsila  *     < E                                  <Data                                    -    -                                                                         e                                                              Arial                                                           Times New Roman                                                 Now is the time for all goodNow is the time for a          P                                                          Times New Roman                                                                            <  8  H                        ;      -           #####;#####-####              (    )      -           (###) ###-####   (000) 000-0000       @@                  X       
              g  
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