Ivlnr/oU/gU1ti n:41:4S Yss St'JKS noufui0815/30/2018 12: ZIS 'ITJ,'trun ra r uoxo rnvrr; o oov r u~ww~ 2/15

STATE OF SOUTH CAROUNA ))

(Caption of Case) )

F~pte: Applicmicn for a Class C Charter Ccrti6cste fmm )John Dos dba Doch Limo )

)Application for a Class C ~etgi'tretcherVan. Zgc3~

WAR".-0 Z0$6

~e~)(Please type orpmu)Submitted byt Here U Go LLC

Address; PO Box 1332

BEFORE THEPUBLIC SERVICE COMMISSION

OF SOUTH CAROl INA

TRANSlPORTATION COVER SHEET

DOCKETNUMBEIL &'~4 - 59

If this is yvw fssr ums gliua m spplivauoe wkk um pSC& you will smbsvs s Docket Number. Ibc Cmcmissioo will assiga one tc ycs. Ifyesksm fiicd with rhc Commission before, s Docket Number wss smisnvd

scd should be entered shove.

Tclephonet 803-888-0412

Fax: 888-578-5498

Other:

NOTL': The cover sheet sod information coatshmd herein neither retdsces nor supplements the filing snd service ofpleadings or other papers

as requited by isw. This form is required for use by tbe Public Service Commhsiou of South Carolina for the purpose of docketing eud must

berigedOurC fetal .

NATURE OF ACTION (Cheek eg that apply)

Q Application - Class A/A Restricted

Q Application. Class C Taxi

Application - Class C Charter

Application- Class C Charter Bus

g Applicafion - Class C Non-Emerge&tcy

Request for Name Change on Ccrdftcate

Request to Amend Scope ofAuthority

Request to Amend 'fariff (rate increase, etc.)

Request to Amend Passenger Limit

g Request

Qx'pplication - Class C Stretcher Van

Q Application- Class E Household Goods

Q Application - Class E Haxsrdous Waste

Q Applicadon

Request for Extension to Comply with Order

I i Request for Order Granting Awhority to Obtam a Cenificate~ ofPublic Convenience snd Necessity to be Rescinded

: Request for Gmcellation ofCertificate

Request for Suspension

P Request for Reinstatement

Exhibit

Late-Filed Exhibit

Letter

Q Pmposed Order

Publisher's Affidavi

Q Reservation Letter

Q Response

Q Return to Petition

Q Other,

++PC ~O

0~cg

If you have any quesdtons about this form, plea,e contact the PUBLIC SERVICE COMMISSION at 803-890-5100. 7

Mar/30Q018 3:41:43 PM SC ORS 8037370815F30/2016 12: EB 'tx/: ltrua'iovvoso riiuri: oooo iooeoo 3/1 5

PUBLIC SERVICE COMMISSION OF SOUTH CAROLINA

101 'Executive Center Drive, Suite 100

Columbia, South Carolina 29210

Phone:(8033 896-5100 Fax:(803) 896-5199

APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NFCFSSITY FOR

OPERATION OF MOTOR VEHICLE CARRIER

CLASS C - STRETCHER VAN R %3t)ate: 3-31-18

VAR SO 2018

Application is hereby made for a Certificate e and Necessity, in accordance with the provision

of S.C. Code Ann., ll 58-23-10, et seri. (1976), ami amendments themto.

1. Name under which business is io be conducted {corporation. Fartnciddp, or sole proprietorship, with or without trade name.)

Here U Go Ll C

1040 Tinker Town Rd. Fairfax SC 29827treat Address of App icant

PO Box 1332 Fairfax SC 29827mg A s o pphcsnt{'rect rom street edifies'03-686-

1hone

888-5754412sx

2. If the Applicant is an LLC or a corporaiion, a copy of the Certificate of Existence from the South Carolina

Secretary of State and the Articles of Incorporation mtist be attached, {If incorporated outside ofSC, attach South

Carolina Secretary of State "Foreigo Corporation" Certificate.)

3. Select Entity Type: (Check one)

g Individual Owner/Sole Pmprietorship

Q Partnership - List names snd address of all person having an interest in the business.

Q Corporation - List names and addresses of two principal officers.

Single member LLC

Jacqueline Murdaugh

PO Box 1332

Fairfax, SC 29827

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Marl30l201 6 3:41:43 PM SC ORS 8037370815'301201ti saints uv:louororvoxv rnvrs ~ vvuuivv~vu 4l15

Applicant is financially able to furnish the services as specified in this application and submits the following

statement of assets and liabilities.

BALANCE SHEET

Balance at Time Application is Filed:

Month March Year 2016

* Total Assets = Total Liabilities and Equity

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Marl30/2016 3:41:43 PM SC ORS 8037370815IQU/auao ac'co aw, IVV' 0 ( W JU l'IIAlVl VV%IV ~ VV'X\&U cfkev v

PROPOSED RATES AND CHARGES FOR SERVICE

ie rtri

$5000 maximum trip price

u t t c estitl

You will only be allowed to operate in those counties checked below. You may request "Statewide"

authority ifyou intend to operate in all counties in South Carotins.

Abbeville

Q Agendaic

Q Anderson

Q Bamberg

Q Bamwell

Q Beaufort

Q Berkeley

P Ctdhoun

Charleston

Q Cherokee

Q Chesterfield

g Clarendon

Q Col leton

Darlington

[J Dillon

Dorchester

Bdgefteld

Fairficld

Q Florence

Q Georgetown

Gteenvilie

Q Greenwood

Hampton

Horry

Jasper

Q Kershsw

Q Lancaster

Laurens

Q Lexington

+Marion

Q Marlboro

hdcCotmick

Q Netvberry

Q Oconee

Q Orangeburg

Pickens

Q Richland

Q Saluda

Q Spattanburg

Q Sumter

Q Union

Q Wi!Iismsburg

Q York

Qx Statewide

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Mar/30/2016 3:41:43 PM SC ORS 8037370815I nu/nvso aa i ao aur sovo r or ooi o rnvri; oooo r oouoo rano' 6/15

DESCRIPTION OF EQUIPMENT

You are not required to own a vehicle to file an application. Howcvcr, prior to being issued a cem6cate by ORE,

you will be required to have obtained a vehicle.

YEAR dt MODEL

WHEEL-CHAIR

EMPTY WEIGHT LIFT

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Mar/30/2018 3:41'43 PM SC ORS 8037370815'30/2018 l2:26 t'u:at/vera/voao rrrum:ooooroouoo 7/15

INSURANCE QUOTE

This foun 'y an V

The insunrnce quote must be complete, listing current insursrxu premiums. At the discretion of the Commission, a copy of current

insurance policies n&ay be required. Do not provide a copy of hmtrsnce policies unless rcquerted. You will uot be required to

purchase insurance until your spplicstioo hss been sppmved and sn order hss been issued by the PSC. TRIS lg ONLY A QUOTE.

The following insurance quote is for.

Here 0 Go LLC

Name of Applicant

PO Sox 1332 Fairfax, SC 29627

Address ofAppgcant

Liability Insurance $ 1 000'000

Thc above quoted premium is for a term of 12 months.

Minimum limits - Bodily injury and property damage limits will not be less

than the following: Limits Quoted

Liability Combined Each Occursnce

Medical Payments per Person

$ 1,000,000

$ 1,000

AdvisorNet Property & Casualty, LLC

arne o Insurance ompany

701 4th Avenue South Suite 1620 Minneapolis, MN 5541 5

orna tce A ess o mpany

I am famiTiar with the Commission's Rules and Regulations relating to insurance mquirements and the above quote

mccts the minimum insurance limitsprescribed. The insurance company making this quote is authorized by ere

South Csmlina Department ofInsurance to do business in South Carolira.

3-31-16Date

See Attached Quote

Authorised Insurance Company Representative's Signature

~TIlfyou wish to self-insure your motor vehicles for liability and property damage, you must comply with S.C. Code

Ann. Sections 56-9-60 and 58-23-910. Por more information, contact Vickie Coker with the Departmen ofMotor

Vehicles at (803) 896-8457.

IFyou wish to apply as a self-insured for workta's compensation coverage in South Carolina you may do so with

the South Camlina Worker's Compensation Commission (WCC) provided that you will be able to: 1) post a surety

bond or letter-of-credit with the WCC for a minimum of $500,000, 2) agree to pay a yearly self-insurance tax, and

3) agree to pay an annual assessment to the South Carolina Second Injury Fund. For more information, contact thc

WCC Self-Insurance Division at (803) 737-5712 or on the wcb at www.wcc.state.sc.us/self-insurance.

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MBr/30l2016 3:50:05 PM'ovlcvJo Ja'on SC ORS 603737M15xv; Jovo /o / vol.o 4 xsUvx i ooov I vo'uxxo rxseo ' 12l15

INANcNI/xxsix66///c,

'I80 Nanhnssl Paint Bk/dMk Gxwe vslsss, Music mxxn

Pious: 0474724700Fsx: 847 RXX8240

/xi/IFH '4'.4

CI)IY'ET)IT

THE A11A6 GROUP OF CO08DANIT5

Ta; ADVISDRI8ET PROP S CAS„LLCAthn«on: NICK MAHLIK

~x'ixs//6

TH GAROU UOTATIOI/I I

Ap"icsnb ere U GO LLCEEsc«velRenewal Of:

Ws are pleased te pnwlde you s quotstlnn for tbe abave risk. Estbnsted annual pmndunw, cover«0s Em«s,snd expasws bass are shown below, NDTE: Ressrdhms ofcovsra06 requssbnl in «w appEaamm cubnil«sd,Our quohEan ls based on Sun«bud %KB Sled cover«so fonna unless o«wrwhe shied. On both new andrenewal quotes, indvldml lines are pdced on an Accoulfr bash and should be oansbhxsd ae such. we w«lnot Euwantse pdchB for "sebct" Bass.

6IOTE: CovemEe snd limits quoted msy differ trom covers«e requeahd In the spp«ca«on.

lf we ars to hsue pallaies par our quotalhn, please provide all requested Information for revhmr and approval.Quotes am subject to hvorable lass experience vs««aathm ami favorable bmpectlan lf not obhlned prior to thsndease of this quota«on. AE quotas «m valid for no more Smn thirty days or the date of expim«on if a mnswsl.

COVERAGE PDRM/

I UNITS

SYMBOL 7 COVERAGE APPUESFOR Alk COVERAGE UNLESSDTHERSR00 NOTED

Farms tc be IxuudsdrCA 2304 xdusicn si kxm/Sm/cA 2304 tsks si su/n /usbd dual muiuslcncsA 8000 Asnnnsd cs/s, cuslcdr ai ccclns suck«Is/ICA 201 8 Pmrsssisnsi 0/m/lom nci ccvusdCBA 0002 Funsi cr Sack/da Exskx/kmCGA 6006 Abuse or Mcknu/hm sxdusianCBA 6008 Wkc b an Iuswsd Rsdstnsd

NOTES:

NON EMERGENCY 1 UNIT

STATED 8 13,000

QUOTE COHTSIGENTON THE FOlLOWINGACCORD 128 12/ 137 61SGNED HONBEDORIED DEDUCllSLE FORMSIGHED NO LOSS STATEMENT

SYMBOL 1 APPUES DUE TO LOSSTICARE

LIABILITY

UNUIM UMITS

COMPREHENSIVECOLUSION

HIRED VEHICLENON OWNED

ADDITIONAL IHSURED

61,000 Umits 8/tcirs)

100IUmks uglaus)

61,000 DEDUCTIBLEtt/Ma DEDUCI'ISLE

PRE68UM

83041.00

622700824600

$100.00

TOTAL PREMIUM

THE ABOVE PREMIUM IS SASED ON A RATING TERRTIORY OF:FAIRFA)I,BC.

PREPARED SY/

UNDSRWRITERPAGE 1 OF 2

Mar/30/2016 3:50:05 PM SC ORS 803737081530/201t3 12:3% 1u:xovara(UOLTE elhi v 13l15

APPLICNIT/INSURED: ~~~ g @~ Lee

GENERAI. CONDfBON8 I

t. AN drtvem must be approved by ASI and must be disclosed stSme of applhagonlblndlng.

2, AN potengsl nsw hires must be submitted to the company for approval.

S. AN drham must quagfy under our Safe Driver Program. ASI reserves the right ta exclude l mlect any

operstoc for any mason who msy otherwise qualify under Sw criteria.

4, We wgl not accept any anfoff same vehhhr aadoasement acgvlty.

THE FOLlOWING INFORMATION IS REQUIRED:

issue InstrucgansAN drtvem over 75 mquirs Ihs OOT Physical forms completed

Complete Nei of sg owned vehhdss Induding lhasa without e bond agrd

Llel alag muniaipslNee ths lnsumdlapplkant is Nceneed to aperats

ANO glair csrwegaSxr mqulrerrlentrl

Capbm of any csrtlgcstss of Insurance snd binders issued

Nan~portscl Operator Deductible Endorsement

CurrenNExplring piling lor ail Nnas

Inspecgan contacd nameUpdsled driver Nst

Name of Medicare Provklsr & Prcndder Number snd/or Sacdai Swvlce Agency conbactsd with

Yehbds registrations/Lease sgmemsnls for sg vshiales used by ths named insured

Mechanical inspecgon mport with photos for ad unNs over 1D model years old

Limousine Inspection wgh photosLace Runs for gm past ~earsComptete Lhno I Taxi I Parauansit Supplemental Appgeadanmust be signed by agent & insured

Na Loss Statement

RENEWALSCompacted snd signed renewal applicagonRenewal InehuatlonsRenewal cerdgasra ot Insurance aml binder

~ Renewal sppkstlon must inane:- Cemplere vehide Inlareesun incbeseg

eeeeeg espeellr- updated gct ef eperslec. Synod vndenrrelegregenrs crxepdlet

~ Ceplee of erl eenlcbr regurresene- ceplee of sil laces egreemmle if eppseebie

Cepue of bandergceneee scen~where eperellng.

fgQES1) If wrgten, the above quote is subject to Asl being nagged of aN vehlcds sddigons wittdn~.

You must sutxng sn endorsement change request to ASL

2) If wrgtsn, ths abave quote ls subject to ASI receiving the abave msngoned Neme wlthbr toys of bln4ng.

Fabws to provide requested Information msy result Nr csnoelbrhan of pobay.

3) 855))Xj) 959~PE A Fes of Sg. wgl be charged to reinslsle sny pohcy csrmegsd for

non-psymenl of prendum during pogcy term.

d) Slgnmi ACORD Appgcsgon is needed at time of binding. ACORD 125 & AGORO 137 SC

5) There Is s charge far addbhnal btsumdltsesors added to pogcy.

PASN20p 2

Mar/30/2016 3:50:05 PM SC ORS 8037370815OU/ZVED JX:JS Au: AOVO ru r VDEO rfturt; tottOD ruusrna raSa:

14/TD

150 Northwest pobn Blvd.

8th Gree Vigsgs, dlhols 00007Phone: OATwnefcoFec 04/-F000240

,th Ii(f..l!l!Ht XY-

eTns stuns sunup 0F corn pnlsss

A

hutslcANSESYICE

G res its Aucr

To: ADVEOONETAtten!Am: SAWINAI I IAWSON

/30I16

Rs: GENERAL UABIUTY OUOTAllONRenewst ofheursd:

ws wa picasso to provide vre s quotation for Ihe above rbx. Estimated annual premiums, based on Onss, exposurehase snd baste oovenxe rvques!ed um stunm hstow. NDTB:

Regardless

of cuvenxe rsquwned hr the sppsusuonsutxnhuuL our quotsOon h assed on Sanded "IBO" ssdror "N C CE" Esd orxerage forms unhes cowwlse Alstsdwaled bsxrw. Dn boot new and mnswal qwme, lndhidusl Ones IPsdrsge, Aulo, etc ) ms pdcsd on su AccoUNTheels snd should be ounsldsred ss such. Ws will not ouwuntee pdotng for "evlscl'ines.

0 ws wu lo issue pc tides psr our quotation, please pevlds sg rsqumesd Information for nwlew snd approval. All

quutte we sub!ed tubworeNe hes wq»rhmou vsrtgoe5on snd favorable Inspsctkm 8 not obtained pdor to thschess of this quolslke. Ag quotes ure vaRI for no moe Ihsn thhty days m the dale ot exptetian If s nmewsl,

CDVBIIAGB FORM:

GENERAL LNBIL/IYCLABB 4005IEXPQOURE: 1

1'OTAL AUTO PRBMXIM&

GENERAL LIABIUTY

PRSMIUSI

$ 1,210

REQUIRED TO ISSUE THB GL POLICY:

TERRORISM ACCEPTANCE ORRBIBCTICNFORM SGNBDO DATBO

ACDRD f25 SIGNED AND DATEDACORD I20

MUST BIND AUTO POLICY TO BIND GLATlAS DOES NOT WRITE MCNCUNE Gt.

THM poLlcY DOEB NDT covBR ANYGARAGE UABIUTY BXPDOURB.

Maria BaNeTmneporlsgon UndelwdtsrGENERAL CONDtTIONS:

GENERAL AGGREGATE $ 1,000,000PRCDS & COOIP CPTS AGGT. $ 1,000,000EACH OCCURRENCE $ 1,000,000PERO 0 ADV INAIRY $ 1,005,000FIRE DAMAGE 1txhoteMEDICAL EXPENSE 0 s,oooIhuv 0NE pe!coroSEXllAL ABUSE AND MOLESTATION IHCLUDEDEACH CIA04 $ 1,leo/tooAGGREGATE $ 1800,000TERRORISM INCLUDED ($1 }

IF ANY ADDITONAL INSURED(8/ARE RECUIRED THE CHARGE IS $50. EACH 2 INCLUDEDUNLESS ENTITY IS A STATE AGENCY.

FEB OF 02ILOO WXL BE CHARGED FOR ANY POLICY CANCELLED FORNDN PAYMENT OF PREMIUM AND REIN6TATED BY THE COMPANV.

THE FQLLowlNG INFORiuIATioN Is REQUIRED:

GENERAL UAEIUTY FORMS/ENDORSEMENTS;CG0067 -Excfuston-Vlotstirm of Statutes Oud Govern E-Mails, Fsx, Phone Calls or Ogler Methods of Sanding

Mstsrtsl or InfcrmsgcnCG2160- Exduslon - Year 2000 Computer-Related and Other Electronic PebtemscG2198-Bilica or sgicaRelatsd Gum ExdusionCMP2007- Lead~IL0021 - Nudear Energy Uability Exckeion Endorsement (Broad Farm)ILF001 -Advtsory Noyes tu pogcyhotders.4!FAcGC2110- Exduslon-4esignated Prohsslonat ServicesCG2146-Abussnr Motestsgon ExcheionCG2167 - Fungi or Bschsrh Exctuslon082244- Exdushn-Services Furnished by Healgt Cere Provides

Marl30/2016 3:50:05 PM SC ORS 8037370815o I oao rnuln; oooo r oowoo 15l15

Ogice ofSecretary ofState Mark Hammond

Certificate of Existence

l, Mark Hammond, Secretary of State of South Carolina Hereby certify that:

HERE U GO LLC, A Limited Liability Company duly organized under the laws of theState of South Carolina on July 17th, 2015, with a duration that is at wiil, has as ofthis date tiled all reports due this office, including its most recent annual report asrequired by section 3~211, paid all fees, taxes and penalties owed to theSecretary of State, that the Secretary of State has not mailed notice to the companythat it is subject to being dissolved by administrative action pursuant to section 33M-809 of the South Carolina Code, and that the company has not filed a certificate ofcancellation as of the date hereof,

Given under my Hand and the Great Seal of theState of South Carolina this 17th day of July,2015

Mark Hammond, Seetetttty efState

Mar/30/201 6 4:21:15 PMuzi a@i COJP Jl JO 0%4QD'3JI JZ

SC ORS 8037370815(HE UPS STORE 3886

1/1 2PAGE 81/11

Tbs UPS Stars 85i,8t. James Avs., Suite 2taooas crialr, 80 89448Fax (843)51-3FI2.

FAX

To

Company

Fax riumber

@Ice~gg ~ll'glS

.'mwia~m

Phone number

: Fax number

Total p'a'ges //'obnumber

I . 4

Ma//30I2016 3:41:43 PM SC ORS 8037370815~30/2016 12: it! nt/.'tsvo rolvolo rnvri.ouu~ ru~~uu a 8/15

Here U Go Ll.C

U.S.D.O.T No. C o.

I. Does Applicant have a Safety Rating from the U.S.D.O.T//

Q Yes No Q Pending (Submit when received,)

If Yes, indicate rating below and provide copy.

Q Satisfactory Q Conditional Q Unsatisfactory

2. Have sny of Applicant's drivers or vehides been p'laces "out of service" by Transport Police safety oAicers in

tbe past twelve (12) months?

Q Yes 9 No

3. Are there cmn;ntly any outstanding judgments against the Applicant?

Q Yes 9 No

IfYes, indicate nature ofjudgetnent(s) against applicant.

4. Is Applicant familiar with all snttutcs and regulations, including safety regulations and govenung for-hire motor

carrier operations in South South Carolina, and does Applicsut agree to opemte in compliance with these

statutes snd regulations?

9 Yes Q No

5, Is App/icant aware of the Commission's insurance requirements and tbe insurance premium costs associated

therewith?

9 Ycs Q No

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SC ORS 8037370815IU i Jove io I vo*o I'aoo i oooo I Uouoo rauo, o 9/15

aaLigcLftolg

1. Applicant has read aud understands Commission Regulation 103-133(8).

Q No

2. Applicant has on file a certified copy of the drive and assistaiu driveA three (3) year driving recordsissued by the SC DMV and such records fram the DMV ofthe state in which the driver or the assistantdriver is or has been domici!ed for such period.

Q No

3, Applicam has obtained and retained the criminal history background checks fiom the state where the driveraad assistant driver live.

9 Yes Q No

4. Applicant understands that all drivers and assistant drivers must have in their possessian at the tiine ofsuch operation valid driver'icenses issued by the SC DMV or the current state of residence of the driveror assisumt driver.

Q No

5. Applicant understands thai all stretcher van certificate holders are prohibited from employing drivers sndassistant drivers who are registered, or required to be registered, as sex offenders with the Soufii CarolinaState Law Enforcement Division or any national registry of sex ofFenders.

Q No

6. Applicant understands that all stretcher van drivers and assistant drivers must possess a current Red CmssFirst Aid ceitification or. an American Safety and Health institute certification, ar cettiftcatian from aprognun that meets or exceeds the certification standards of the Red Cross First Aid or the Amexican Safetyand Health histitute, and Adult Canliopulmonary Resuscitation (CPR) certification. Yes Q No

7. Applicant understands that the driver's and assistant driver's Red Cross First Aid certification must berenewed every three (3) years and the Adult CPR certification must be renewed annually.

Q No

g. Applicant undexstands that an individual must not bc transported in a stretcher van if the individual has awritten statement fiom a licensed physician prohibiting transportation in a stretcher van.

Q No

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l/tar/surete 3:otruo t" ss HC t/tee tttrn/3/Utt1530/2016 12 t 26 TU: Jtrun/n ruoso meme; oooo v «w~v 10/15

PURLIC SERVICE COMMISSION OF SOUTH CAROLBuA

101 BXBCUTIVL'ENTER DRIVE, SUIIE 100

COLUMBIA, S(NJIII CAROLINA 29210

Applicant is familiar with the provision of S.C. Code Ann. 1't58-23-10, et sect.(1976), and amendments thereto,

and R.103-100 through R.103-241 of the Commission's Rules and Regulations for Motor Camera (Volume 26,

S.C. Code Ann. Regna 1976), and R.38400 through R38-503 of the Department ofPublic Safety's Rules and

Regulations for Motor Carriers (Volume 23A, S.C. Code Ann., 1976) and amendments thereto, and hereby

promises compliance therewith,

S.C. Code Ann. Section 58-3-250 states, in part, that every Anal order of: the Commission must be served by

electronic service, registered or certified mail, upon the parties to tbe pmceeding or their attorneys.

Please check the applicable bore

The Applicant AORBBS ta receive ihture Cunnnission orders related to the Apphcsnt's suthority in South Cern!inc

through the Canuuission's cScrvice System, 1he Appllcsnt smhorizes thc Commttmon to serve its orders by wring the

email address ss it sppesm on psge one of this Appllcstion, To sign np for eService non five&ious, plesre vish www psc.

sc.gov ta crests s My DMS sceount.

Thc Applicant DOES NOT AGREE to receive foture Cammission orders related to the Applicant's uuttmrity in South

Csralitts through the Cammissian's egervice System.

The Applicant for Bte Certificate ofPublic Convenience and Necessity as set forth in the foregoing, swear or

aflirm that all statements contained in the above application are trna and correct.

MemberTite o App tcant(e.g. resident, Owner„etc.)

STATE OF SO

COIINTY OF

)WORN TO 'ORE

This ~ day of 20~1

Commission Expires

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