Federal Communications Commission DA 12-644
1
Before the
Federal Communications Commission
Washington, D.C. 20554
In the Matter of
Sky Angel U.S., LLC,
Complainant,
v. 
Discovery Communications, LLC, et al.
Defendants.
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MB Docket No. 12-80
File No. CSR-8605-P
ORDER
Adopted:  April 25, 2012 Released:  April 25, 2012
By the Chief, Media Bureau:
I. INTRODUCTION
1. For the reasons discussed below, we adopt the Protective Order set forth in Appendix A 
to ensure that certain confidential documents and information submitted by the parties in the above-
captioned proceeding are afforded adequate protection.
II. BACKGROUND
2. On March 24, 2010, Sky Angel U.S., LLC (“Sky Angel”) filed a program access 
complaint against Discovery Communications, LLC and its affiliate, Animal Planet, L.L.C. (collectively, 
“Discovery”).1 Along with its complaint, Sky Angel filed a petition for a standstill of its affiliation 
agreement with Discovery.2 The Media Bureau denied the standstill petition.3
3. On April 13, 2010, Sky Angel and Discovery (collectively, the “Parties”) filed a joint 
motion requesting that the Commission enter a protective order in this proceeding.4 The Parties explain 
that the Complaint and related materials involve a confidential agreement between the Parties and the 
  
1 See Sky Angel U.S., LLC v. Discovery Communications, LLC, et al., Program Access Complaint, MB Docket No. 
12-80, File No. CSR-8605-P (filed March 24, 2010) (the “Complaint”).
2 See Sky Angel U.S., LLC v. Discovery Communications, LLC, et al., Emergency Petition for Temporary 
Standstill, MB Docket No. 12-80, File No. CSR-8605-P (filed March 24, 2010); see also Sky Angel U.S., LLC v. 
Discovery Communications, LLC, et al., Renewed Petition for Temporary Standstill, MB Docket No. 12-80, File 
No. CSR-8605-P (filed May 27, 2011).
3 See Sky Angel U.S., LLC, Order, 25 FCC Rcd 3879 (MB, 2010).
4 See Joint Motion for Entry of Protective Order, MB Docket No. 12-80, File No. CSR-8605-P (filed April 13, 2010) 
(“Motion”) (attaching proposed protective order).
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negotiations and communications related thereto.5 The Parties further state that Sky Angel’s discovery 
requests seek copies of Discovery’s “most sensitive, trade secret, confidential business documents, and 
both Parties’ trade secret, confidential business documents and information will be at issue in this 
proceeding.”6 The Parties seek enhanced protection of highly confidential sensitive data that could place 
them at a significant competitive disadvantage if disclosed to their competitors or, with respect to some 
documents, to the other party’s employees.7 They submit that the Commission has long recognized that 
the competitively sensitive data at issue here, such as the terms and pricing of business negotiations and 
customer agreements, are appropriately subject to enhanced confidential treatment.8 Due to the highly 
confidential nature of this information, the Parties propose that the Commission adopt a Protective Order 
based in large part on the Commission’s model program access Protective Order to limit access to the 
information.9 The proposed Protective Order includes a category of highly confidential information 
called “Outside Counsel’s Eyes Only,” to which only the Outside Counsels of Record for Sky Angel and 
Discovery would have access and to which employees of Sky Angel and Discovery would not have 
access.10
III. DISCUSSION
4. Based on representations made by Sky Angel and Discovery, we conclude that a 
Protective Order is needed to provide enhanced confidential treatment for certain information submitted 
in this proceeding.  The Parties explain that the information sought to be protected is competitively 
sensitive and that additional protection is warranted so that such information is closely guarded and not 
made available publicly. Accordingly, we adopt the Protective Order set forth in Appendix A.  Any party 
seeking access to highly confidential documents subject to this Protective Order shall request access 
pursuant to the terms of the Protective Order and must sign the Declaration provided as Attachment A to 
this Protective Order.
5. The attached Protective Order reflects the desire of Sky Angel and Discovery, given the 
highly confidential nature of certain information designated Outside Counsel’s Eyes Only, to preclude 
employees of each from access to this information.  We do not intend by this Order to prejudge this issue.  
If either party believes that it is necessary for purposes of effectively adjudicating this proceeding that 
specific employees be granted access to the highly confidential information designated Outside Counsel’s 
Eyes Only, it may file a motion to amend the Protective Order.  At a minimum, such motion should 
include: (i) the title, name, and job description for each employee for which access to the Outside 
Counsel’s Eyes Only information is sought; (ii) the reason why that employee’s access to the Outside 
Counsel’s Eyes Only information is necessary to the effective adjudication of this proceeding; and (iii) 
why experts and consultants outside of that party’s employ cannot perform the same function.  In no event 
will access be granted to employees in a position to use the Outside Counsel’s Eyes Only information for 
competitive commercial or business purposes.
  
5 See id. at 1.
6 See id.
7 See id. at 1-2.
8 See id. at 2.
9 See id.
10 Proposed Protective Order and Paragraph 2.f.
Federal Communications Commission DA 12-644
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6. In addition to Paragraph 4 of the attached Protective Order, we clarify that a party filing 
documents with the Commission that contain Highly Confidential Information (“Highly Confidential 
Filing”) must file one copy of the Highly Confidential Filing and, where feasible, two copies of the 
Highly Confidential Filing in redacted form (“Redacted Highly Confidential Filing”).  A Highly 
Confidential Filing must be accompanied by a cover letter stating: “CONTAINS PRIVILEGED AND 
HIGHLY CONFIDENTIAL INFORMATION - DO NOT RELEASE – SUBJECT TO 
PROTECTIVE ORDER IN SKY ANGEL U.S., LLC v. DISCOVERY COMMUNICATIONS, 
LLC, ET AL., FILE NO. CSR-8605-P.”  As set forth in Paragraph 4, each page of this document 
containing Highly Confidential Information shall be stamped with the preceding statement or with the 
following statement:  “CONTAINS INFORMATION FOR OUTSIDE COUNSEL’S EYES ONLY –
DO NOT RELEASE – SUBJECT TO PROTECTIVE ORDER IN SKY ANGEL U.S., LLC v. 
DISCOVERY COMMUNICATIONS, LLC. ET AL., FILE NO. CSR-8605-P.”  Redacted Highly 
Confidential Filings must also be accompanied by a cover letter stating: “REDACTED – FOR PUBLIC 
INSPECTION,” and the cover letter should also state that the Submitting Party is filing an unredacted 
version of such documents.
IV. ORDERING CLAUSES
7. Accordingly, we ADOPT AND ISSUE the Protective Order attached at APPENDIX A 
pursuant to Sections 4(i), 4(j), and 628 of the Communications Act as amended, 47 U.S.C. §§ 154(i), (j) 
and 548, Sections 0.457(d) and 76.1003(k) of the Commission’s rules, 47 C.F.R. §§ 0.457(d) and 
76.1003(k), and Section 4 of the Freedom of Information Act, 5 U.S.C. § 552(b)(4), and such Protective 
Order is effective upon its adoption.
8. This action is taken pursuant to authority delegated by Section 0.283 of the 
Commission’s rules.11
FEDERAL COMMUNICATIONS COMMISSION
William T. Lake
Chief, Media Bureau
  
11 47 C.F.R. § 0.283.
Federal Communications Commission DA 12-644
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APPENDIX A
In the Matter of
Sky Angel U.S., LLC,
Complainant,
v. 
Discovery Communications, LLC, et al.
Defendants.
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)
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)
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MB Docket No. 12-80
File No. CSR-8605-P
PROTECTIVE ORDER
1. This Protective Order is intended to facilitate and expedite the review of documents filed 
in this proceeding or obtained from a person in the course of discovery that contain trade secrets and 
privileged or confidential commercial or financial information.  It establishes the manner in which 
“Highly Confidential Information,” as that term is defined herein, is to be treated.  The Order is not 
intended to constitute a resolution of the merits concerning whether any Highly Confidential Information 
would be released publicly by the Commission upon a proper request under the Freedom of Information 
Act or other applicable law or regulation, including 47 C.F.R. § 0.442.
2. Definitions.
a. Authorized Representative.  “Authorized Representative” shall have the meaning 
set forth in Paragraph 8.
b. Commission.  “Commission” means the Federal Communications Commission 
or any arm of the Commission acting pursuant to delegated authority.
c. Highly Confidential Information.  “Highly Confidential Information” means (i) 
operational, financial, revenue, and other sensitive business information; (ii) program carriage 
agreements, the terms thereof, or negotiations related to same, or any part thereof; (iii) other information 
submitted to the Commission by the Submitting Party that has been so designated by the Submitting Party 
and which the Submitting Party has determined in good faith constitutes trade secrets or commercial or 
financial information which is privileged or confidential within the meaning of Exemption 4 of the 
Freedom of Information Act, 5 U.S.C. § 552(b)(4); and (iv) information submitted to the Commission by 
the Submitting Party that has been so designated by the Submitting Party and which the Submitting Party 
has determined in good faith falls within the terms of Commission orders designating the items for 
treatment as Highly Confidential Information.  Highly Confidential Information includes additional 
copies of, notes, and information derived from Highly Confidential Information.
d. Declaration.  “Declaration” means Attachment A to this Protective Order.
e. Outside Counsel of Record.  “Outside Counsel of Record” means the firm(s) of 
attorneys, or sole practitioner(s), as the case may be, along with their employees (such as attorneys, 
secretaries, support staff, and paralegals), representing either complainant Sky Angel U.S., LLC (“Sky 
Angel”) or defendants Discovery Communications, LLC and Animal Planet, LLC (“Discovery”) 
Federal Communications Commission DA 12-644
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(collectively, the “Parties”) in this proceeding.  For the avoidance of doubt, Outside Counsel of Record 
shall exclude any employee of either Sky Angel or Discovery.
f. Outside Counsel’s Eyes Only.  Highly Confidential Information that consists of 
or concerns a contract, terms of carriage, negotiation, or agreement between a Party and any non-Party 
may be further designated by the Submitting Party as for Outside Counsel’s Eyes Only and may not be 
disclosed to any person or entity other than Outside Counsel of Record as defined in paragraph 2.e of this 
Protective Order.
g. Reviewing Party.  “Reviewing Party” means a person or entity participating in 
this proceeding that receives Highly Confidential information.
h. Submitting Party.  “Submitting Party” means a person or entity that seeks 
confidential treatment of Highly Confidential Information pursuant to this Protective Order.
3. Claim of Confidentiality.  The Submitting Party may designate information as “Highly 
Confidential Information” consistent with the definition of that term in Paragraph 2.c of this Protective 
Order.  The Submitting Party may furthermore designate some or all of the Highly Confidential 
Information as “Outside Counsel’s Eyes Only” consistent with the definition of that term in Paragraph 2.f 
of this Protective Order.  The Commission may, sua sponte or upon petition, pursuant to 47 C.F.R. §§ 
0.459 and 0.461, determine that all or part of the information claimed as “Highly Confidential 
Information” is not entitled to such treatment.
4. Procedures for Claiming Information is Highly Confidential.  Highly Confidential 
Information submitted to the Commission shall be filed under seal and shall bear on the front page in bold 
print, “CONTAINS PRIVILEGED AND HIGHLY CONFIDENTIAL INFORMATION – DO NOT 
RELEASE – SUBJECT TO PROTECTIVE ORDER IN SKY ANGEL U.S., LLC v. DISCOVERY 
COMMUNICATIONS, LLC, ET AL., FILE NO. CSR-8605-P.”  Highly Confidential Information 
shall be segregated by the Submitting Party from all non-confidential information submitted to the 
Commission.  Information designated as for Outside Counsel’s Eyes Only shall be so designated on the 
face of each page containing such information, and the first page of any document containing such 
information shall state “CONTAINS INFORMATION FOR OUTSIDE COUNSEL’S EYES ONLY –
DO NOT RELEASE – SUBJECT TO PROTECTIVE ORDER IN SKY ANGEL U.S., LLC v. 
DISCOVERY COMMUNICATIONS, LLC, ET AL., FILE NO. CSR-8605-P.”  To the extent a 
document contains both Highly Confidential Information, including Outside Counsel’s Eyes Only 
information, and non-confidential information, the Submitting Party shall designate the specific portions 
of the document claimed to contain Highly Confidential Information, including Outside Counsel’s Eyes 
Only information if applicable, and shall, where feasible, also submit a redacted version not containing 
Highly Confidential Information.  By designating information as “Highly Confidential Information,” a 
Submitting Party signifies that it has determined in good faith that the information should be subject to 
protection under the Freedom of Information Act, the Commission’s implementing rules, and this 
Protective Order.  Information that was designated by the parties as “Highly Confidential” or “Outside 
Counsel’s Eyes Only” before entry of this Protective Order shall be treated for all purposes as if it were so 
designated under the procedures set forth in this paragraph, notwithstanding any differences in the 
language of such designation.
5. Storage of Highly Confidential Information at the Commission.  The Secretary of the 
Commission or other Commission staff to whom Highly Confidential Information is submitted shall place 
the Highly Confidential Information in a non-public file.  Highly Confidential Information shall be 
Federal Communications Commission DA 12-644
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segregated in the files of the Commission, and shall be withheld from inspection by any person not bound 
by the terms of this Protective Order, unless such Highly Confidential Information is released from the 
restrictions of this Order either through agreement of the parties, or pursuant to the order of the 
Commission or a court having jurisdiction.
6. Commission Access to Highly Confidential Information.  Highly Confidential 
Information shall be made available to the Commission and its staff.  Consultants under contract to the 
Commission may obtain access to Highly Confidential Information only if they have signed, as part of 
their employment contract, a non-disclosure agreement the scope of which includes the Highly 
Confidential Information, or if they execute the attached Declaration.
7. Disclosure.  Outside Counsel of Record may not disclose information designated as 
Outside Counsel’s Eyes Only to any other person or entity beyond those included in the definition of 
Outside Counsel of Record in section 2.e. of this Protective Order.  Outside Counsel of Record or such 
other person designated pursuant to Paragraph 6 may disclose Highly Confidential Information to other 
Authorized Representatives to whom disclosure is permitted under the terms of paragraph 8 of this 
Protective Order only after advising such Authorized Representatives of the terms and obligations of the 
Order.  In addition, before Authorized Representatives may obtain access to Highly Confidential 
Information, each Authorized Representative must execute the attached Declaration.
8. Authorized Representatives shall be limited to:
a. Employees of the Parties, including such persons requested by counsel to furnish 
technical or other expert advice or service, or otherwise engaged to prepare material for the express 
purpose of formulating filings in this proceeding; and
b. Outside consultants or experts retained for the purpose of assisting Outside 
Counsel of Record in this proceeding, provided that such outside consultants or experts are not employees 
of Sky Angel or Discovery (as relevant) and are not involved in the analysis underlying the business 
decisions of any competitor of the Submitting Party and do not participate directly in those business 
decisions.
9. Procedures for Obtaining Access to Highly Confidential Information. In all cases where 
access to Highly Confidential Information is sought pursuant to paragraphs 7 or 8, before reviewing or 
having access to any Highly Confidential Information, each person seeking such access shall execute the 
Declaration in Attachment A and file it with the Commission and serve it upon the Submitting Party 
through their Outside Counsel of Record, so that the Declaration is received by the Submitting Party at 
least five (5) business days prior to such person’s reviewing or having access to such Submitting Party’s 
Highly Confidential Information.  Each Submitting Party shall have an opportunity to object to the 
disclosure of its Highly Confidential Information to any such persons.  Any objection must be filed at the 
Commission and served on Outside Counsel of Record representing, retaining, or employing such person 
as promptly as practicable after receipt of the relevant Declaration.  Until any such objection is resolved 
by the Commission and, if appropriate, any court of competent jurisdiction, and unless such objection is 
resolved in favor of the person seeking access, persons subject to an objection from a Submitting Party 
shall not have access to Highly Confidential Information.  If there is no objection or once such objection 
is resolved, the Submitting Party shall serve the documents of such party containing Highly Confidential 
Information on the requesting party’s Outside Counsel of Record, or if so requested, will make such 
material available for review at the offices of the Submitting Party’s Outside Counsel of Record.
Federal Communications Commission DA 12-644
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10. Copies of Highly Confidential Information.  The Submitting Party shall provide a copy of 
the Highly Confidential Material to Authorized Representatives upon request and may charge a 
reasonable copying fee not to exceed twenty five cents per page.  Authorized Representatives may make 
additional copies of Highly Confidential Information but only to the extent required and solely for the 
preparation and use in this proceeding.  The original copy and all other copies of the Highly Confidential 
Information shall remain in the care and control of Authorized Representatives at all times.  Authorized 
Representatives having custody of any Highly Confidential Information shall keep the documents 
properly and fully secured from access by unauthorized persons at all times.
11. Filing of Declaration.  Counsel for Reviewing Parties shall provide to the Submitting 
Party and the Commission a copy of the attached Declaration for each Authorized Representative within 
five (5) business days after the attached Declaration is executed, or by any other deadline that may be 
prescribed by the Commission.
12. Use of Highly Confidential Information.  Highly Confidential Information shall not be 
used by any person granted access under this Protective Order for any purpose other than for use in this 
proceeding (including any subsequent administrative or judicial review), shall not be used for competitive 
business purposes, and shall not be used or disclosed except in accordance with this Order.  This shall not 
preclude the use of any material or information that is in the public domain or has been developed 
independently by any other person who has not had access to the Highly Confidential Information nor 
otherwise learned of its contents.
13. Pleadings Using Highly Confidential Information.  Submitting Parties and Reviewing 
Parties may, in any pleadings that they file in this proceeding, reference the Highly Confidential 
Information, but only if they comply with the following procedures:
a. Any portions of the pleadings that contain or disclose Highly Confidential 
Information must be redacted from the remainder of the pleadings and filed under seal;
b. The unredacted versions containing or disclosing Highly Confidential 
Information must be covered by a separate letter referencing this Protective Order;
c. Each page of any Party’s filing that contains or discloses Highly Confidential 
Information subject to this Order must be clearly marked pursuant to Paragraph 4 of this Protective Order; 
and
d. The Highly Confidential portion(s) of the pleading, to the extent they are 
required to be served, shall be served upon the Secretary of the Commission and Outside Counsel of 
Record for the Parties.  Such Highly Confidential portions shall be served under seal, and shall not be 
placed in the Commission’s Public File unless the Commission directs otherwise (with notice to the 
Submitting Party and an opportunity to comment on such proposed disclosure).  A Party filing a pleading 
containing Highly Confidential Information shall also file a Redacted Public Version of the pleading 
containing no Highly Confidential Information, which copy shall be placed in the Commission’s public 
files. A Party may provide courtesy copies of pleadings containing Highly Confidential Information to 
Commission staff so long as the notations required by this Paragraph and Paragraph 4 are not removed.
14. Client Consultation.  Nothing in this Protective Order shall prevent or otherwise restrict 
Outside Counsel of Record from rendering advice to their clients relating to the conduct of this 
proceeding and any subsequent judicial proceeding arising therefrom and, in the course thereof, relying 
Federal Communications Commission DA 12-644
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generally on examination of Highly Confidential Information; provided, however, that in rendering such 
advice and otherwise communicating with such client, Outside Counsel of Record shall not disclose 
Outside Counsel’s Eyes Only information to their clients.
15. Violations of Protective Order.  Should a Reviewing Party that has properly obtained 
access to Highly Confidential Information under this Protective Order violate any of its terms, it shall 
immediately convey that fact to the Commission and to the Submitting Party.  Further, should such 
violation consist of improper disclosure or use of Highly Confidential Information, the violating party 
shall take all necessary steps to remedy the improper disclosure or use.  The Violating Party shall also 
immediately notify the Commission and the Submitting Party, in writing, of the identity of each party 
known or reasonably suspected to have obtained the Highly Confidential Information through any such 
disclosure.  The Commission retains its full authority to fashion appropriate sanctions for violations of 
this Protective Order, including but not limited to suspension or disbarment of attorneys from practice 
before the Commission, forfeitures, cease and desist orders, and denial of further access to Highly 
Confidential Information in this or any other Commission proceeding.  Nothing in this Protective Order 
shall limit any other rights and remedies available to the Submitting Party at law or equity against any 
party using Highly Confidential Information in a manner not authorized by this Protective Order.
16. Termination of Proceeding.  The provisions of this Protective Order shall not terminate at 
the conclusion of this proceeding.  Within two weeks after final resolution of this proceeding (which 
includes any administrative or judicial appeals), persons described in paragraphs 7 and 8 shall destroy or 
return to the Submitting Party the relevant documents containing Highly Confidential Information as well 
as all copies and derivative materials made, and shall certify in a writing served on the Commission and 
the Submitting Party that no material whatsoever derived from such Highly Confidential Information has 
been retained by any person having access thereto, except that Outside Counsel of Record may retain, 
under the continuing strictures of this Protective Order, two copies of pleadings (one of which may be in 
electronic format) submitted on behalf of a Party.  Any Highly Confidential Information contained in any 
copies of pleadings retained by Outside Counsel of Record to a party pursuant to this paragraph shall be 
protected from disclosure or use indefinitely in accordance with this Protective Order unless such Highly 
Confidential Information is released from the restrictions of this Protective Order either through 
agreement of the parties, or pursuant to the order of the Commission or a court having jurisdiction.  The 
provisions of this paragraph regarding the retention of Highly Confidential Information, any documents 
containing such information, and copies of same, shall not be construed to apply to the Commission or its 
staff.
17. No Waiver of Confidentiality.  Disclosure of Highly Confidential Information as 
provided herein shall not be deemed a waiver by the Submitting Party of any privilege or entitlement to 
confidential treatment of such Highly Confidential Information.  Reviewing Parties, by viewing these 
materials:  (a) agree not to assert any such waiver; (b) agree not to use information derived from any 
Highly Confidential materials to seek disclosure in any other proceeding; and (c) agree that accidental 
disclosure of Highly Confidential Information shall not be deemed a waiver of the privilege.
18. Subpoena by Courts, Departments, or Agencies.  If a court or a federal or state 
department or agency issues a subpoena or orders production of Highly Confidential Information that a 
party has obtained under terms of this Protective Order, such party shall promptly notify in writing each 
Submitting Party of the pendency of such subpoena or order.  Consistent with the independent authority 
of any court, department, or agency, such notification must be accomplished such that the Submitting 
Party has a full opportunity to oppose such production, which shall be at least five (5) business days prior 
to the production or disclosure of any Highly Confidential Information.
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19. Additional Rights Preserved.  The entry of this Protective Order is without prejudice to 
the rights of the Submitting Party to apply for additional or different protection where it is deemed 
necessary or to the rights of Reviewing Parties to request further or renewed disclosure of Highly 
Confidential Information.
20. Effect of Protective Order.  This Protective Order constitutes an Order of the Commission 
and also a binding agreement between the Reviewing Party or other person executing the attached 
Declaration and the Submitting Party.
21. Authority.  This Protective Order is issued pursuant to Sections 4(i) and 4(j) of the 
Communications Act as amended, 47 U.S.C. §§ 154(i), (j) and 47 C.F.R. §§ 0.457(d) and 76.1003(k), and 
Section 4 of the Freedom of Information Act, 5 U.S.C. § 552(b)(4).
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Attachment A
In the Matter of
Sky Angel U.S., LLC,
Complainant,
v. 
Discovery Communications, LLC, et al.
Defendants.
)
)
)
)
)
)
)
)
)
MB Docket No. 12-80
File No. CSR-8605-P
DECLARATION
I, __________________________________________, hereby declare under penalty of perjury that I 
have read the Protective Order that has been entered by the Commission in this proceeding, and I 
understand it.  I agree to be bound by its terms pertaining to the treatment of Highly Confidential 
Information, including to the extent designated as Outside Counsel’s Eyes Only, submitted by parties to 
this proceeding, and I agree that I shall not disclose or use Highly Confidential Information except as 
allowed by the Protective Order.
Without limiting the foregoing, to the extent that I have any employment, affiliation, or role with any 
person or entity other than a conventional private law firm (such as, but not limited to, a lobbying or 
public interest organization), I acknowledge specifically that my access to any Highly Confidential 
Information obtained as a result of the Protective Order is due solely to my capacity as (1) Outside 
Counsel of Record or (2) other person described in paragraphs 7 or 8 of the foregoing Protective Order, 
and that I will not use such Highly Confidential Information in any other capacity; nor will I disclose such 
Highly Confidential Information except as specifically provided in the Protective Order.
I acknowledge that it is my obligation to ensure that: (1) Highly Confidential Information is used only as 
provided in the Protective Order; and (2) documents containing Highly Confidential Information are not 
duplicated except as specifically permitted by the terms of the Protective Order, and I certify that I have 
verified that there are in place procedures, at my firm or office, to prevent unauthorized disclosure of 
Highly Confidential Information.
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I acknowledge that a violation of the Protective Order is a violation of an order of the Federal 
Communications Commission. I acknowledge that this Protective Order is also a binding agreement 
between the undersigned and the Submitting Party.
(signed)
(printed name)
(representing)
(title)
(employer)
(address)
(phone)
(date)