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GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No.
GPA Involved
Day of Week Date Notified Time
Total No.Vehicles
Total No.Injured
GPA Division InvolvedYes No
Arrived Time
Road ofOccurrence
At IntersectionWith
Not at IntersectionBut Approx.
Nearest Road/LandmarkOf
BerthNo.
Row/LaneNo.
Slot No.
LOCATI
ON
Ft.AtNear
Other Location
Weather Surface Condition Light ConditionType Accident
Vehicle
Address (St./Rd. - Apt. No. - P.O. Box)
City State Zip
Drivers License No. State Class
Sex Race
Employer Home Phone
S.S.N. D.O.B.
Vehicle
Address (St./Rd. - Apt. No. - P.O. Box)
City State Zip
ClassStateDrivers License No.
Sex Race
Employer Home Phone
D.O.B.S.S.N.
Work Phone Work Phone
Driver Driver
Address
City State Zip
Vehicle Leased To
Year Make
V.I.N. Color
Lic. Plate No. State
Vehicle
Model
Year
Trailer/Chassis Lic. Plate No. State Year
Trailer/Container No. Length
Chassis No. Length
Insurance Co. Policy No.
Direction of Travel Speed Limit
Vehicle
Address
City State
Vehicle Leased To
Year Make Model
ColorV.I.N.
Lic. Plate No. State
StateTrailer/Chassis Lic. Plate No.
Trailer/Container No. Length
LengthChassis No.
Insurance Co. Policy No.
Speed LimitDirection of Travel
Zip
Year
Year
Owner Owner
Trailer Type Vehicle Type Trailer TypeVehicle Type
Company VehicleIdentification No. Identification No.
Company Vehicle
Vehicle Maneuver
Damage
Vehicle Removed By
Vehicle Maneuver
Vehicle Removed By
DamagePoint of Initial Contact Point of Initial Contact
201501030012 Saturday 1/3/2015 8:30:00 AM
CONTAINER OPERATIONSþ ¨ 2 1
CHATHAM DRIVE
100 West TOMOCHICHI RD¨þ
ANGLE DRY DAYLIGHT
CHANEY TERRY
2181 FOX STREET
SAVANNAH GA 31402
054077444 GA C
M BLACK
GPA 912-695-7056
054-07-7444 10/5/1972
1REVERE GEORGE WILLIAM
2492 QUACCO ROAD
POOLER GA 31322
052348446 GA CM
M BLACK
GEORGIA PORTS AUTHORITY330-942-3773
269-82-7600 2/11/1984
(912)964-3811
2
TICO TERMINAL SERVICES
75 BRAMPTON RD.
GARDEN CITY GA 31408
2013 TICO
1T9NS4ASODR825019 WHITE
JO13057
Jockey Truck
0
0
GEORGIA PORTS AUTHORITY
West 20
1REVERE JUANITA COSPER
2492 QUACCO RD
POOLER GA 31402
1999 FORD
1FAFP4041XF174298 RED
AWG9306 GA
MUSTANG
2015
0
0
COUNTRY G10A5286460
East 20
2
JOCKEY TRK- TRAILER
Turning Left
SLIGHT
PARICK GILMORE GPA ASSISTANT MANAGER
2 RIGHT SIDE
PASSENGER CAR
Straight
EXTENSIVE
SAPPS TOWING
4 LEFT SIDE
8:34:00 AM
CHATHAM ICTF YARD
Object Struck
Damage Other Than Vehicle
Injuries
Witnesses
Narrative
Investigated By Agency/Dept.Other Agency
Officer C.R.N.
PhotographsTaken
By
Investigating Officer Watch
Report Checked By
Report Date
Date Checked
YesNo
YesNo
Report Checked By Date Checked
Injured Taken To Taken By EMS Noti. Time EMS Arr. Time Hosp. Arr. Time
Notifications
1/4/2015
JOCKEY TRUCK VS. POV
þ¨ 123 OFFICER Jeffrey McCombes201501030012
þ¨ 123 OFFICER Jeffrey McCombes
123 OFFICER Jeffrey McCombes 0545-1815 1/3/2015
1/5/201548 Lieutenant Mario F Stefanski
Name Address Phone No.912-921-084211927 IDLEWOOD DR SAVANNAH GA 31419DAMEWOOD WILLIAM
Name Company/Dept Time Responded To SceneGEORGIA PORTS AUTHORITY POLICE 8:30:00 AM þ ¨ NoYesRYAN , JAMESGPA OPERATION ASSISTANT MANAGER8:30:00 AM þ ¨ NoYesGILMORE , PATRICKGPA SAFETY MANAGER 8:55:00 AM þ ¨ NoYesPAGE , PATRICKGPA RISK MANAGEMENT 8:55:00 AM ¨ þ NoYesJANDOVITZ , BETTY JGPA RISK MANAGEMENT 11:00:00 AM ¨ þ NoYesSTAGNITTO , SUSAN
VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELING EAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2 PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE AN IMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUE TO THE IMPROPER LEFT TURN.
16 Sergeant James M Ryan
SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60 8:40:00 AM 8:54:00 AM
Diagram
GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No. Day of Week Date Notified Time Arrived Time201501030012 Saturday 1/3/2015 8:30:00 AM 8:34:00 AM
Accident Number
201501030012Agency NCIC
GA0250800Accident Date
01/03/2015Georgia Ports Authority - Accident Report Continuation
I SPOKE TO THE DRIVER OF VEHICLE #2, MR. GEORGE REVERE, AND HE STATED, THE DRIVER OF VEHICLE #1 DROVE INTO HIS DRIVER'S SIDE DOOR AS HE WAS DRIVING STRAIGHT ON CHATHAM DRIVE. HE ADVISED VEHICLE #1 NEVER SLOWED DOWN OR STOPPED, "HE JUST TURNED RIGHT INTO ME". HE STATED HE BANGED HIS HEAD ON THE DRIVER'S SIDE WINDOW AND HE COMPLAINED OF LOWERED BACK PAIN AND DIZZINESS. I NOTIFIED GPAPD DISPATCH OF THE INJURIES, AND THEY CONTACTED SOUTHSIDE FIRE EMS TO COME TO THE SCENE. I NOTICED THE POINT OF IMPACT ON HIS DRIVER'S SIDE DOOR AS WELL AS DAMAGE TO THE FRONT LEFT FENDER, WHEEL WELL, TIRE, RIM, FRONT BUMPER, LEFT FRONT HEADLIGHTS, BROKEN DRIVER'S SIDE WINDOW, BROKEN FRONT WINDSHIELD, AND DAMAGED HOOD. THERE WAS DEBRIS AND VEHICLE FLUIDS LAYING ON THE GROUND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN ON CHATHAM DRIVE. DRIVER #1, MR. TERRY CHANEY, STATED HE WAS DRIVING WEST ON CHATHAM DRIVE ABOUT TO TURN LEFT INTO THE CUSTOMS PORTAL AREA. HE STATED HE NEVER SAW MR. REVERE'S MUSTANG. HE INITIALLY STATED TO ME ON SCENE, "I DIDN'T EVEN LOOK OVER THERE. I JUST TURNED". HE STATED HE THEN FELT THE COLLISION BETWEEN BOTH VEHICLES. MR. CHANEY ADVISED HE WAS NOT INJURED ON SCENE AND REFUSED EMS. I ISSUED MR. CHANEY A GEORGIA PORTS AUTHORITY SAFETY VIOLATION NOTICE FOR IMPROPER LEFT TURN (CAD0378), BUT HE REFUSED TO SIGN IT ON SCENE. HE THEN CHANGED HIS TESTIMONY STATING, "HE (VEHICLE#2) DROVE INTO MY TRUCK". I NOTICED SLIGHT FRONT LEFT BUMPER DAMAGE TO HIS JOCKEY TRUCK (13057). I THEN SPOKE TO THE WITNESS, MR. WILLIAM DAMEWOOD, AND HE STATED HE WAS IN HIS JOCKEY TRUCK BEHIND MR. CHANEY AT THE TIME OF THE COLLISION. HE ADVISED MR REVERE CAME TO A COMPLETE STOP AT THE STOP SIGN AND DROVE FORWARD. AS MR. REVERE WAS DRIVING FORWARD, MR. CHANEY TURNED LEFT INTO HIM CAUSING THE ACCIDENT. HE STATED MR. CHANEY NEVER SLOWED DOWN OR STOPPED BEFORE THE LEFT TURN. ALL THREE PARTIES PROVIDED WRITTEN STATEMENTS ON SCENE, AND POSSESSED VALID TWIC AND GPA CREDENTIALS. I INVENTORIED MR. REVERE'S FORD MUSTANG AND THEN HAD GPAPD DISPATCH CALL FOR A HEAD OUT TOWING SERVICE TO REMOVE HIS VEHICLE. BOTH PARTIES DRIVER'S LICENSES WERE VALID AND THEIR VEHICLES HAD ACTIVE INSURANCE COVERAGE. SAPPS TOWING ARRIVED ON SCENE AND REMOVED THE CAR AND CLEANED THE DEBRIS AND VEHICLE FLUIDS FROM THE ROADWAY.
CLEARED EXCEPTIONAL
ADDITIONAL REMARKS
Report By: OFFICER Jeffrey McCombes Page of
Injured Taken To By:
EMS Notified Time
Report By:
Witness(es): Name
EMS Arrival Time Hospital Arrival Time Photos Taken: Yes No By:
Department Report Date Checked By: Date Checked
DOT MICROFILM NUMBER (DO NOT WRITE IN THIS SPACE)
Address City State Zip Code Telephone No.
Accident Number Agency NCIC No. GEORGIA UNIFORMMOTOR VEHICLE ACCIDENT REPORT
County Date Rec. By DPS
Date Day of Week Time Off. Arrived Total Number Of: InsideCity Of:Vehicles Injuries Fatalities
Road ofOccurrence
At ItsIntersection
With
Corrected Report?Yes
Suppl. To Original?Yes
o o o o o o oSun M T W Th F S
Not At ItsIntersection But
oo
oo
oo
MilesFeet
o1
12
34
Interstate 2 o o oLowest St. Rt. Co. Road 4 City St.3
NorthSouth
EastWest
And Continuing in theDirection Checked AboveThe Next Reference Point is
Of:
1 2 3 4o o o oInterstate Lowest St. Rt. Co. Road City St.
1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line
1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line
Hit and Run?Yes
COMMERCIAL VEHICLES ONLYCarrier NameVehicle #
No. of Axles
Vehicle Config.
Address
C.D.L.?Vehicle Placarded? 1
If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:
Ran Off Road
State Zip
G.V.W.R. Fed. Reportable Cargo Body Type1 o 2 oYes No
I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate
oo
1 o Yes 2 o No C.D.L. Suspended?Hazardous Materials?
Released?
1 o 2Yes o No1
1Yes 2 No
Yes 2 Noo o
o o
Down Hill Runaway Cargo Loss or Shift Separation of Units
Carrier NameVehicle #Address
No. of Axles
Vehicle Config.
C.D.L?Vehicle Placarded?1
If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:
Ran Off Road Down Hill Runaway
o Yes 2 o No
Cargo Loss or Shift Separation ofUnits
State Zip
G.V.W.R.o o1 Yes 2 No
Fed. Reportable Cargo Body Type
I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate
oo
o o o o
o oo o
o o1 Yes 2 No 1 Yes 2 No
Yes No 1 Yes 2 No1 Yes 2 No
C.D.L. Suspended?Hazardous Materials?
Released?2
Driver #
Ped o
Last Name First Middle Driver #
Ped
Last Name First Middle
Address Address
State Zip DOB State Zip DOB
oo Male State oo Male
o
Female Female
City
Driver's License No.
PostedSpeed
Year
VIN
Tag #
Trailer Tag #
Sameoas Driver
Address
City
Removed By
AlcoholTestDriverConditionVehicleCondition
Most Harmful EventTraffic Control
Insurance Co. Policy No.
Class State
City
Driver's License No.
PostedSpeed
Make Model Telephone No.
Vehicle Color
State County Year
State County Year
Owner's Last Name First Middle
State Zip
o oRequest List
Type Results DrugTest
Type Results
Directionof TravelVehicleManeuver
VisionObscuredPedestrianManeuver
Contributing Factors
Vehicle Class Vehicle TypeDevice Inoperative? o oYes No
Insurance Co. Policy No.
Year Make Model Telephone No.
VIN
Tag #
Trailer Tag #
Address
o Sameas Driver
City
Removed By
AlcoholTestDriverConditionVehicleCondition
Most Harmful EventTraffic Control
Vehicle Color
State County
State County
First
Year
Year
MiddleOwner's Last Name
State
o
Zip
oRequest List
Directionof TravelVehicleManeuver
Vehicle ClassDevice Inoperative?
Contributing Factors
Vehicle Type
Type Results DrugTest
Type Results
o oYes No
VisionObscuredPedestrianManeuver
Class
DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447
SAVANNAH GA 31402 10/05/1972
054077444 C GA
o
oþ
20 GEORGIA PORTS AUTHORITY
2013 TICO Jockey Truck 912-695-7056
1T9NS4ASODR825019 WHITE
JO13057
o
75 BRAMPTON RD.
GARDEN CITY GA 31408
PARICK GILMORE GPA ASSISTANT MANAGER
2 0
2181 FOX STREET
2 0
1 4 1 13
1 1 011 1 77
o o
þo
1 CHANEY TERRY
TICO TERMINAL SERVICES
POOLER GA 31322 02/11/1984
052348446 CM GA
o
oþ
20 COUNTRY G10A5286460
1999 FORD MUSTANG 330-942-3773
1FAFP4041XF174298 RED
AWG9306 GA CHATHAM 2015
o
2492 QUACCO RD
POOLER GA 31402
SAPPS TOWING
2 0
2492 QUACCO ROAD
2 0
1 3 1 1
1 5 011 1 17
o þ
þo
2 REVERE GEORGE WILLIAM
REVERE JUANITA COSPER
201501030012 GA0250800 CHATHAM
GARDEN CITY0128:348:30þoooooo
01/03/2015
o þ
CHATHAM DRIVEo o o o o o
100 oþ
oo
oþ
TOMOCHICHI RDo þ o o o
oo o o o
912-921-084211927 IDLEWOOD DR SAVANNAH, GA 31419DAMEWOOD WILLIAM
SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60
8:40 8:54
GEORGIA PORTS AUTHORITY POLICE DEPARTMENT
OFFICER Jeffrey McCombes
OFFICER Jeffrey McCombes Lieutenant Mario F Stefanski 01/05/2015
0
0 0 o o 0
0oo
o o o oo o o oo o
00
0
0 0 o o 0
0oo
o o o oo o o oo o
00
01/03/2015
¨
¨
¨
þ ¨
REMARKS
CITATIONS - VEHICLE # CITATIONS - VEHICLE #
First HarmfulEvent
VEH. # VEH. #
Number of Occupants
Point Of Initial Contact
Damage To Vehicles
SKID DISTANCEBEFORE IMPACT
AFTER Width Of Road
Damage OtherThan Vehicle:
Owner:
Occupants Driver #
Driver #
Or Pedestrian #
Or Pedestrian #
AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAG
Last Name First Address City State Zip
VEH FOR SAFETY AIRTAKEN
VEH.
VEH.
VEH.
VEH.
Traffic-WayFlow
Weather Surface Cond. Light Cond. Manner OfCollision
Location atArea of Impact
RoadComp.
Road Def. Road Character
PAGE OF
X X X X XXXX XXXX XXXX XXXX XXXXX XXXX
Construction/Maintenance Zone
0
Accident No. 201501030012
DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447
1 2
11 2 0 1 1 1 1 2 1 11
122
2144
01
01
02
02
1 0 2 1 3 2 02 4 1 1 3 2 2
2 4
VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELINGEAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE ANIMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUETO THE IMPROPER LEFT TURN.
GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No.
GPA Involved
Day of Week Date Notified Time
Total No.Vehicles
Total No.Injured
GPA Division InvolvedYes No
Arrived Time
Road ofOccurrence
At IntersectionWith
Not at IntersectionBut Approx.
Nearest Road/LandmarkOf
BerthNo.
Row/LaneNo.
Slot No.
LOCATI
ON
Ft.AtNear
Other Location
Weather Surface Condition Light ConditionType Accident
Vehicle
Address (St./Rd. - Apt. No. - P.O. Box)
City State Zip
Drivers License No. State Class
Sex Race
Employer Home Phone
S.S.N. D.O.B.
Vehicle
Address (St./Rd. - Apt. No. - P.O. Box)
City State Zip
ClassStateDrivers License No.
Sex Race
Employer Home Phone
D.O.B.S.S.N.
Work Phone Work Phone
Driver Driver
Address
City State Zip
Vehicle Leased To
Year Make
V.I.N. Color
Lic. Plate No. State
Vehicle
Model
Year
Trailer/Chassis Lic. Plate No. State Year
Trailer/Container No. Length
Chassis No. Length
Insurance Co. Policy No.
Direction of Travel Speed Limit
Vehicle
Address
City State
Vehicle Leased To
Year Make Model
ColorV.I.N.
Lic. Plate No. State
StateTrailer/Chassis Lic. Plate No.
Trailer/Container No. Length
LengthChassis No.
Insurance Co. Policy No.
Speed LimitDirection of Travel
Zip
Year
Year
Owner Owner
Trailer Type Vehicle Type Trailer TypeVehicle Type
Company VehicleIdentification No. Identification No.
Company Vehicle
Vehicle Maneuver
Damage
Vehicle Removed By
Vehicle Maneuver
Vehicle Removed By
DamagePoint of Initial Contact Point of Initial Contact
201501030012 Saturday 1/3/2015 8:30:00 AM
CONTAINER OPERATIONSþ ¨ 2 1
CHATHAM DRIVE
100 West TOMOCHICHI RD¨þ
ANGLE DRY DAYLIGHT
CHANEY TERRY
2181 FOX STREET
SAVANNAH GA 31402
054077444 GA C
M BLACK
GPA 912-695-7056
054-07-7444 10/5/1972
1REVERE GEORGE WILLIAM
2492 QUACCO ROAD
POOLER GA 31322
052348446 GA CM
M BLACK
GEORGIA PORTS AUTHORITY330-942-3773
269-82-7600 2/11/1984
(912)964-3811
2
TICO TERMINAL SERVICES
75 BRAMPTON RD.
GARDEN CITY GA 31408
2013 TICO
1T9NS4ASODR825019 WHITE
JO13057
Jockey Truck
0
0
GEORGIA PORTS AUTHORITY
West 20
1REVERE JUANITA COSPER
2492 QUACCO RD
POOLER GA 31402
1999 FORD
1FAFP4041XF174298 RED
AWG9306 GA
MUSTANG
2015
0
0
COUNTRY G10A5286460
East 20
2
JOCKEY TRK- TRAILER
Turning Left
SLIGHT
PARICK GILMORE GPA ASSISTANT MANAGER
2 RIGHT SIDE
PASSENGER CAR
Straight
EXTENSIVE
SAPPS TOWING
4 LEFT SIDE
8:34:00 AM
CHATHAM ICTF YARD
Object Struck
Damage Other Than Vehicle
Injuries
Witnesses
Narrative
Investigated By Agency/Dept.Other Agency
Officer C.R.N.
PhotographsTaken
By
Investigating Officer Watch
Report Checked By
Report Date
Date Checked
YesNo
YesNo
Report Checked By Date Checked
Injured Taken To Taken By EMS Noti. Time EMS Arr. Time Hosp. Arr. Time
Notifications
1/4/2015
JOCKEY TRUCK VS. POV
þ¨ 123 OFFICER Jeffrey McCombes201501030012
þ¨ 123 OFFICER Jeffrey McCombes
123 OFFICER Jeffrey McCombes 0545-1815 1/3/2015
1/5/201548 Lieutenant Mario F Stefanski
Name Address Phone No.912-921-084211927 IDLEWOOD DR SAVANNAH GA 31419DAMEWOOD WILLIAM
Name Company/Dept Time Responded To SceneGEORGIA PORTS AUTHORITY POLICE 8:30:00 AM þ ¨ NoYesRYAN , JAMESGPA OPERATION ASSISTANT MANAGER8:30:00 AM þ ¨ NoYesGILMORE , PATRICKGPA SAFETY MANAGER 8:55:00 AM þ ¨ NoYesPAGE , PATRICKGPA RISK MANAGEMENT 8:55:00 AM ¨ þ NoYesJANDOVITZ , BETTY JGPA RISK MANAGEMENT 11:00:00 AM ¨ þ NoYesSTAGNITTO , SUSAN
VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELING EAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2 PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE AN IMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUE TO THE IMPROPER LEFT TURN.
16 Sergeant James M Ryan
SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60 8:40:00 AM 8:54:00 AM
Diagram
GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No. Day of Week Date Notified Time Arrived Time201501030012 Saturday 1/3/2015 8:30:00 AM 8:34:00 AM
Accident Number
201501030012Agency NCIC
GA0250800Accident Date
01/03/2015Georgia Ports Authority - Accident Report Continuation
I SPOKE TO THE DRIVER OF VEHICLE #2, MR. GEORGE REVERE, AND HE STATED, THE DRIVER OF VEHICLE #1 DROVE INTO HIS DRIVER'S SIDE DOOR AS HE WAS DRIVING STRAIGHT ON CHATHAM DRIVE. HE ADVISED VEHICLE #1 NEVER SLOWED DOWN OR STOPPED, "HE JUST TURNED RIGHT INTO ME". HE STATED HE BANGED HIS HEAD ON THE DRIVER'S SIDE WINDOW AND HE COMPLAINED OF LOWERED BACK PAIN AND DIZZINESS. I NOTIFIED GPAPD DISPATCH OF THE INJURIES, AND THEY CONTACTED SOUTHSIDE FIRE EMS TO COME TO THE SCENE. I NOTICED THE POINT OF IMPACT ON HIS DRIVER'S SIDE DOOR AS WELL AS DAMAGE TO THE FRONT LEFT FENDER, WHEEL WELL, TIRE, RIM, FRONT BUMPER, LEFT FRONT HEADLIGHTS, BROKEN DRIVER'S SIDE WINDOW, BROKEN FRONT WINDSHIELD, AND DAMAGED HOOD. THERE WAS DEBRIS AND VEHICLE FLUIDS LAYING ON THE GROUND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN ON CHATHAM DRIVE. DRIVER #1, MR. TERRY CHANEY, STATED HE WAS DRIVING WEST ON CHATHAM DRIVE ABOUT TO TURN LEFT INTO THE CUSTOMS PORTAL AREA. HE STATED HE NEVER SAW MR. REVERE'S MUSTANG. HE INITIALLY STATED TO ME ON SCENE, "I DIDN'T EVEN LOOK OVER THERE. I JUST TURNED". HE STATED HE THEN FELT THE COLLISION BETWEEN BOTH VEHICLES. MR. CHANEY ADVISED HE WAS NOT INJURED ON SCENE AND REFUSED EMS. I ISSUED MR. CHANEY A GEORGIA PORTS AUTHORITY SAFETY VIOLATION NOTICE FOR IMPROPER LEFT TURN (CAD0378), BUT HE REFUSED TO SIGN IT ON SCENE. HE THEN CHANGED HIS TESTIMONY STATING, "HE (VEHICLE#2) DROVE INTO MY TRUCK". I NOTICED SLIGHT FRONT LEFT BUMPER DAMAGE TO HIS JOCKEY TRUCK (13057). I THEN SPOKE TO THE WITNESS, MR. WILLIAM DAMEWOOD, AND HE STATED HE WAS IN HIS JOCKEY TRUCK BEHIND MR. CHANEY AT THE TIME OF THE COLLISION. HE ADVISED MR REVERE CAME TO A COMPLETE STOP AT THE STOP SIGN AND DROVE FORWARD. AS MR. REVERE WAS DRIVING FORWARD, MR. CHANEY TURNED LEFT INTO HIM CAUSING THE ACCIDENT. HE STATED MR. CHANEY NEVER SLOWED DOWN OR STOPPED BEFORE THE LEFT TURN. ALL THREE PARTIES PROVIDED WRITTEN STATEMENTS ON SCENE, AND POSSESSED VALID TWIC AND GPA CREDENTIALS. I INVENTORIED MR. REVERE'S FORD MUSTANG AND THEN HAD GPAPD DISPATCH CALL FOR A HEAD OUT TOWING SERVICE TO REMOVE HIS VEHICLE. BOTH PARTIES DRIVER'S LICENSES WERE VALID AND THEIR VEHICLES HAD ACTIVE INSURANCE COVERAGE. SAPPS TOWING ARRIVED ON SCENE AND REMOVED THE CAR AND CLEANED THE DEBRIS AND VEHICLE FLUIDS FROM THE ROADWAY.
CLEARED EXCEPTIONAL
ADDITIONAL REMARKS
Report By: OFFICER Jeffrey McCombes Page of
Injured Taken To By:
EMS Notified Time
Report By:
Witness(es): Name
EMS Arrival Time Hospital Arrival Time Photos Taken: Yes No By:
Department Report Date Checked By: Date Checked
DOT MICROFILM NUMBER (DO NOT WRITE IN THIS SPACE)
Address City State Zip Code Telephone No.
Accident Number Agency NCIC No. GEORGIA UNIFORMMOTOR VEHICLE ACCIDENT REPORT
County Date Rec. By DPS
Date Day of Week Time Off. Arrived Total Number Of: InsideCity Of:Vehicles Injuries Fatalities
Road ofOccurrence
At ItsIntersection
With
Corrected Report?Yes
Suppl. To Original?Yes
o o o o o o oSun M T W Th F S
Not At ItsIntersection But
oo
oo
oo
MilesFeet
o1
12
34
Interstate 2 o o oLowest St. Rt. Co. Road 4 City St.3
NorthSouth
EastWest
And Continuing in theDirection Checked AboveThe Next Reference Point is
Of:
1 2 3 4o o o oInterstate Lowest St. Rt. Co. Road City St.
1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line
1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line
Hit and Run?Yes
COMMERCIAL VEHICLES ONLYCarrier NameVehicle #
No. of Axles
Vehicle Config.
Address
C.D.L.?Vehicle Placarded? 1
If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:
Ran Off Road
State Zip
G.V.W.R. Fed. Reportable Cargo Body Type1 o 2 oYes No
I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate
oo
1 o Yes 2 o No C.D.L. Suspended?Hazardous Materials?
Released?
1 o 2Yes o No1
1Yes 2 No
Yes 2 Noo o
o o
Down Hill Runaway Cargo Loss or Shift Separation of Units
Carrier NameVehicle #Address
No. of Axles
Vehicle Config.
C.D.L?Vehicle Placarded?1
If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:
Ran Off Road Down Hill Runaway
o Yes 2 o No
Cargo Loss or Shift Separation ofUnits
State Zip
G.V.W.R.o o1 Yes 2 No
Fed. Reportable Cargo Body Type
I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate
oo
o o o o
o oo o
o o1 Yes 2 No 1 Yes 2 No
Yes No 1 Yes 2 No1 Yes 2 No
C.D.L. Suspended?Hazardous Materials?
Released?2
Driver #
Ped o
Last Name First Middle Driver #
Ped
Last Name First Middle
Address Address
State Zip DOB State Zip DOB
oo Male State oo Male
o
Female Female
City
Driver's License No.
PostedSpeed
Year
VIN
Tag #
Trailer Tag #
Sameoas Driver
Address
City
Removed By
AlcoholTestDriverConditionVehicleCondition
Most Harmful EventTraffic Control
Insurance Co. Policy No.
Class State
City
Driver's License No.
PostedSpeed
Make Model Telephone No.
Vehicle Color
State County Year
State County Year
Owner's Last Name First Middle
State Zip
o oRequest List
Type Results DrugTest
Type Results
Directionof TravelVehicleManeuver
VisionObscuredPedestrianManeuver
Contributing Factors
Vehicle Class Vehicle TypeDevice Inoperative? o oYes No
Insurance Co. Policy No.
Year Make Model Telephone No.
VIN
Tag #
Trailer Tag #
Address
o Sameas Driver
City
Removed By
AlcoholTestDriverConditionVehicleCondition
Most Harmful EventTraffic Control
Vehicle Color
State County
State County
First
Year
Year
MiddleOwner's Last Name
State
o
Zip
oRequest List
Directionof TravelVehicleManeuver
Vehicle ClassDevice Inoperative?
Contributing Factors
Vehicle Type
Type Results DrugTest
Type Results
o oYes No
VisionObscuredPedestrianManeuver
Class
DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447
SAVANNAH GA 31402 10/05/1972
054077444 C GA
o
oþ
20 GEORGIA PORTS AUTHORITY
2013 TICO Jockey Truck 912-695-7056
1T9NS4ASODR825019 WHITE
JO13057
o
75 BRAMPTON RD.
GARDEN CITY GA 31408
PARICK GILMORE GPA ASSISTANT MANAGER
2 0
2181 FOX STREET
2 0
1 4 1 13
1 1 011 1 77
o o
þo
1 CHANEY TERRY
TICO TERMINAL SERVICES
POOLER GA 31322 02/11/1984
052348446 CM GA
o
oþ
20 COUNTRY G10A5286460
1999 FORD MUSTANG 330-942-3773
1FAFP4041XF174298 RED
AWG9306 GA CHATHAM 2015
o
2492 QUACCO RD
POOLER GA 31402
SAPPS TOWING
2 0
2492 QUACCO ROAD
2 0
1 3 1 1
1 5 011 1 17
o þ
þo
2 REVERE GEORGE WILLIAM
REVERE JUANITA COSPER
201501030012 GA0250800 CHATHAM
GARDEN CITY0128:348:30þoooooo
01/03/2015
o þ
CHATHAM DRIVEo o o o o o
100 oþ
oo
oþ
TOMOCHICHI RDo þ o o o
oo o o o
912-921-084211927 IDLEWOOD DR SAVANNAH, GA 31419DAMEWOOD WILLIAM
SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60
8:40 8:54
GEORGIA PORTS AUTHORITY POLICE DEPARTMENT
OFFICER Jeffrey McCombes
OFFICER Jeffrey McCombes Lieutenant Mario F Stefanski 01/05/2015
0
0 0 o o 0
0oo
o o o oo o o oo o
00
0
0 0 o o 0
0oo
o o o oo o o oo o
00
01/03/2015
¨
¨
¨
þ ¨
REMARKS
CITATIONS - VEHICLE # CITATIONS - VEHICLE #
First HarmfulEvent
VEH. # VEH. #
Number of Occupants
Point Of Initial Contact
Damage To Vehicles
SKID DISTANCEBEFORE IMPACT
AFTER Width Of Road
Damage OtherThan Vehicle:
Owner:
Occupants Driver #
Driver #
Or Pedestrian #
Or Pedestrian #
AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAG
Last Name First Address City State Zip
VEH FOR SAFETY AIRTAKEN
VEH.
VEH.
VEH.
VEH.
Traffic-WayFlow
Weather Surface Cond. Light Cond. Manner OfCollision
Location atArea of Impact
RoadComp.
Road Def. Road Character
PAGE OF
X X X X XXXX XXXX XXXX XXXX XXXXX XXXX
Construction/Maintenance Zone
0
Accident No. 201501030012
DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447
1 2
11 2 0 1 1 1 1 2 1 11
122
2144
01
01
02
02
1 0 2 1 3 2 02 4 1 1 3 2 2
2 4
VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELINGEAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE ANIMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUETO THE IMPROPER LEFT TURN.
ADDITIONAL REMARKS
Accident Number Agency NCIC Accident Date Georgia Uniform Motor Vehicle Report Continuation
Report By:Page of
OCCUPANTS
Injured Taken To: By:
Witness - NamePhone
Address
Last Name First Address City State Zip AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAGVEH FOR SAFETY AIRTAKEN
OFFICER Jeffrey McCombes
Attach to DOT-523Attach to DOT-523 DOT-523C (12/03)
201501030012 GA0250800 01/03/2015
3 4
I SPOKE TO THE DRIVER OF VEHICLE #2, MR. GEORGE REVERE, AND HE STATED, THEDRIVER OF VEHICLE #1 DROVE INTO HIS DRIVER'S SIDE DOOR AS HE WAS DRIVING STRAIGHTON CHATHAM DRIVE. HE ADVISED VEHICLE #1 NEVER SLOWED DOWN OR STOPPED, "HE JUSTTURNED RIGHT INTO ME". HE STATED HE BANGED HIS HEAD ON THE DRIVER'S SIDE WINDOWAND HE COMPLAINED OF LOWERED BACK PAIN AND DIZZINESS. I NOTIFIED GPAPD DISPATCHOF THE INJURIES, AND THEY CONTACTED SOUTHSIDE FIRE EMS TO COME TO THE SCENE. INOTICED THE POINT OF IMPACT ON HIS DRIVER'S SIDE DOOR AS WELL AS DAMAGE TO THEFRONT LEFT FENDER, WHEEL WELL, TIRE, RIM, FRONT BUMPER, LEFT FRONT HEADLIGHTS,BROKEN DRIVER'S SIDE WINDOW, BROKEN FRONT WINDSHIELD, AND DAMAGED HOOD. THEREWAS DEBRIS AND VEHICLE FLUIDS LAYING ON THE GROUND APPROXIMATELY 60 FEET EASTOF THE STOP SIGN ON CHATHAM DRIVE. DRIVER #1, MR. TERRY CHANEY, STATED HE WAS DRIVING WEST ON CHATHAM DRIVEABOUT TO TURN LEFT INTO THE CUSTOMS PORTAL AREA. HE STATED HE NEVER SAW MR.REVERE'S MUSTANG. HE INITIALLY STATED TO ME ON SCENE, "I DIDN'T EVEN LOOK OVERTHERE. I JUST TURNED". HE STATED HE THEN FELT THE COLLISION BETWEEN BOTHVEHICLES. MR. CHANEY ADVISED HE WAS NOT INJURED ON SCENE AND REFUSED EMS. IISSUED MR. CHANEY A GEORGIA PORTS AUTHORITY SAFETY VIOLATION NOTICE FORIMPROPER LEFT TURN (CAD0378), BUT HE REFUSED TO SIGN IT ON SCENE. HE THEN CHANGEDHIS TESTIMONY STATING, "HE (VEHICLE#2) DROVE INTO MY TRUCK". I NOTICED SLIGHT FRONTLEFT BUMPER DAMAGE TO HIS JOCKEY TRUCK (13057). I THEN SPOKE TO THE WITNESS, MR. WILLIAM DAMEWOOD, AND HE STATED HE WAS INHIS JOCKEY TRUCK BEHIND MR. CHANEY AT THE TIME OF THE COLLISION. HE ADVISED MRREVERE CAME TO A COMPLETE STOP AT THE STOP SIGN AND DROVE FORWARD. AS MR.REVERE WAS DRIVING FORWARD, MR. CHANEY TURNED LEFT INTO HIM CAUSING THEACCIDENT. HE STATED MR. CHANEY NEVER SLOWED DOWN OR STOPPED BEFORE THE LEFTTURN.
Report By: Page ofOFFICER Jeffrey McCombesAttach to DOT-523 DOT-523C (12/03)
ADDITIONAL REMARKS
Accident Number Agency NCIC Accident Date Georgia Uniform Motor Vehicle Report Continuation
Report By:Page of
OCCUPANTS
Injured Taken To: By:
Witness - NamePhone
Address
Last Name First Address City State Zip AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAGVEH FOR SAFETY AIRTAKEN
OFFICER Jeffrey McCombes
Attach to DOT-523Attach to DOT-523 DOT-523C (12/03)
ALL THREE PARTIES PROVIDED WRITTEN STATEMENTS ON SCENE, AND POSSESSEDVALID TWIC AND GPA CREDENTIALS. I INVENTORIED MR. REVERE'S FORD MUSTANG AND THENHAD GPAPD DISPATCH CALL FOR A HEAD OUT TOWING SERVICE TO REMOVE HIS VEHICLE.BOTH PARTIES DRIVER'S LICENSES WERE VALID AND THEIR VEHICLES HAD ACTIVEINSURANCE COVERAGE. SAPPS TOWING ARRIVED ON SCENE AND REMOVED THE CAR ANDCLEANED THE DEBRIS AND VEHICLE FLUIDS FROM THE ROADWAY.
CLEARED EXCEPTIONAL
Report By: Page ofOFFICER Jeffrey McCombes 4 4
GPA MDADT Software Page 1 EMW-2013-PU-00097 15-BM-10175598 01/08/15
Federal Grant Requirements Maritime Domain Awareness Data Tracking
EMW-2013-PU-00097 15-BM-10175598 1. The Georgia Ports Authority (GPA) is updating its current Port Police incident tracking software
Maritime Domain Awareness Data Tracking which is funded by a Federal FEMA Port Security Grant.
2. In accordance with standards set by this Grant, grant recipients and vendors of this project
must comply with all applicable federal standards and regulations:
A. Access to Records (44 CFR Part 13.36(i)(10))
Access by the grantee, the subgrantee, the Federal grantor agency, the Comptroller General of the United States, or any of their duly authorized representatives to any books, documents, papers, and records of the contractor which are directly pertinent to that specific contract for the purpose of making audit, examination, excerpts, and transcriptions.
B. Awarding Agency Reporting Requirements (44 CFR Part 13.36(i)(7))
1. Successful Vendor shall submit semi-annual performance reports to the Georgia Ports Authority Project Manager for the periods ending June 30 and December 31 by the tenth day of the following month.
2. The final performance report will be due 15 days after the earliest of project end date or grant project end date.
3. Performance reports will contain brief information on the following:
a. A comparison of actual accomplishments to the objectives established for the period.
b. The reasons for slippage if established objectives were not met.
c. Additional pertinent information including, when appropriate, analysis and explanation of any anomalies to the period objectives.
C. Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)
Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures and certifications are forwarded from tier to tier up to the recipient. (See attached Certification)
GPA MDADT Software Page 2 EMW-2013-PU-00097 15-BM-10175598 01/08/15
D. Clean Air Act and the Federal Water Pollution Control Act (44 CFR Part 13.36(i)(12)) Compliance with all applicable standards, orders, or requirements issued under section 306 of the Clean Air Act (42 U.S.C. 1857(h), section 508 of the Clean Water Act (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency regulations (40 CFR part 15).
E. Copyrights (44 CFR Part 13.36 (i)(9) 1. The Federal awarding agency reserves a royalty-free, nonexclusive, and irrevocable
license to reproduce, publish or otherwise use, and to authorize others to use, for Federal Government purposes.
2. The copyright in any work developed under a grant, subgrant, or contract under a grant or subgrant; and
3. Any rights of copyright to which a grantee, subgrantee or a contractor purchases ownership with grant support.
F. Debarment and Suspension (44 CFR Part 13.35)
Guarantees and subgrantees must not make any award or permit any award (subgrant or contract) at any tier to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549, “Debarment and Suspension.” (Attached Certification must also be obtained from all lower tiers).
G. Energy Policy and Conservation Act (44 CFR Part 13.36(i)(13))
Mandatory standards and policies relating to energy efficiency which are contained in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (Pub. L. 94-163, 89 Stat. 871).
H. Records Retention Requirements (44 CFR Part 13.36(i)(11)) Retention of all required records for three years after grantees or subgrantees make final payments and all other pending matters are closed.
I. Rights to Inventions Made Under a Contract or Agreement (44 CFR Part 13.36(i)(8)) Notice of awarding agency requirements and regulations pertaining to patent rights with respect to any discovery or invention which arises or is developed in the course of or under such contract.
J. Termination (44 CFR Part 13.36(i)(2)), 44 CFR Part 13.43, and 44 CFR Part 13.44 GPA may terminate this contract in whole or in part at any time for convenience, or because of the vendor failure or default to fulfill its contract obligations, by written notice to the vendor.
K. Trafficking in Persons (2 CFR Part 175)
GPA MDADT Software Page 3 EMW-2013-PU-00097 15-BM-10175598 01/08/15
REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF THE OFFERORS
Certification Regarding Lobbying This certification is required for an award of a contract utilizing Federal grant or subrecipient
funding exceeding $100,000. The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form – LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
(3) The undersigned shall require that the language of this certification, be included in the
award documents for all subawards at all tiers (including subcontracts, subgrants, and contacts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Offeror Name: __________________________________________________________________ Signature: _____________________________________________________________________ Printed Name: __________________________________________________________________ Title: __________________________________________________ Date: __________________
GPA MDADT Software Page 4 EMW-2013-PU-00097 15-BM-10175598 01/08/15
REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF THE
OFFERORS
Certification Regarding Debarment, Suspension, Proposed Debarment, and Other Responsibility Matters-Primary Covered Transactions
1. The prospective primary participant certifies to the best of its knowledge and belief, that it and
its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any Federal department or agency;
b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
c. Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and
d. Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default. 2. Where the prospective primary participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal. 3. The undersigned shall require that the language of this certification, be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contacts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
Offeror Name: _________________________________________________________________ DUNS#: _______________________________________________________________________ Signature: _____________________________________________________________________ Printed Name: __________________________________________________________________ Title: __________________________________________________ Date: __________________