The opinion
Orlando Villalba (SBN 232165)
1 Orlando.Villalba@capstonelawyers.com
Helga Hakimi (SBN 257381)
2 Helga.Hakimi@capstonelawyers.com
Roxanna Tabatabaeepour (SBN 260187)
3 Roxanna.Taba@capstonelawyers.com
Capstone Law APC
4 1875 Century Park East, Suite 1000
Los Angeles, California 90067
5 Telephone: (310) 556-4811
Facsimile: (310) 943-0396
6
Attorneys for Plaintiff Jose Jesus Avalos-Aviles
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Adam Y. Siegel (SBN 238568)
8 Adam.siegel@jacksonlewis.com
Martin P. Vigodnier (SBN 311834)
9 Martin.vigodnier@jacksonlewis.com
JACKSON LEWIS P.C.
10 725 South Figueroa Street, Suite 2500
Los Angeles, California 90017-5408
11 Telephone: (213) 689-0404
Facsimile: (213) 689-0430
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Attorneys for Defendant
13 RED ROBIN INTERNATIONAL, INC.
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15 UNITED STATES DISTRICT COURT
16 EASTERN DISTRICT OF CALIFORNIA
17
JOSE JESUS AVALOS-AVILES,
18 individually, and on behalf of other No. 2:22-cv-1257 DAD DB
members of the general public
19 similarly situated, and as an STIPULATED PROTECTIVE ORDER
aggrieved employee pursuant to the
20 Private Attorneys General Act
(“PAGA”),
21
22 Plaintiff,
23 vs.
24 RED ROBIN INTERNATIONAL,
INC. dba RED ROBIN BURGER
25 AND SPIRITS EMPORIUMS, a
Nevada corporation; and DOES 1
26 through 10, inclusive,
27
1 1. INTRODUCTION
2 1.1 PURPOSES AND LIMITATIONS
3 Discovery in this action may involve production of confidential, proprietary, or
4 private information for which special protection from public disclosure and from use
5 for any purpose other than prosecuting this litigation may be warranted. Accordingly,
6 the Parties hereby stipulate to and petition the Court to enter the following Stipulated
7 Protective Order. The Parties acknowledge that this Order does not confer blanket
8 protections on all disclosures or responses to discovery and that the protection it affords
9 from public disclosure and use extends only to the limited information or items that are
10 entitled to confidential treatment under applicable legal principles. The Parties further
11 acknowledge, as set forth in Section 12.3 below, that this Order does not entitle them to
12 file Confidential Information under seal; Civil Local Rule 141 sets forth the procedures
13 that must be followed and the standards that will be applied when a Party seeks
14 permission from the Court to file material under seal.
15 1.2 GOOD CAUSE STATEMENT
16 As a wage and hour class action, this action is likely to involve discovery of
17 putative class members’ contact information and other sensitive information in which
18 the putative class members have a legally protected privacy interest under the California
19 Constitution. See, e.g., Belaire-West Landscape, Inc. v. Superior Court, 149 Cal. App.
20 4th 554 (2007). This action may additionally involve discovery of records that include
21 customer and pricing lists and other valuable research, development, commercial,
22 financial and proprietary information for which special protection from public
23 disclosure and from use for any purpose other than prosecution of this action is
24 warranted. Such confidential and proprietary materials and information consist of,
25 among other things, confidential business or financial information, tax filings,
26 information regarding confidential business practices, and other confidential research,
27 development, or commercial information, information otherwise generally unavailable
1 to the public, or which may be privileged or otherwise protected from disclosure under
2 state or federal statutes, court rules, case decisions, or common law.
3 Accordingly, to expedite the flow of information, to facilitate the prompt
4 resolution of disputes over confidentiality of discovery materials, to adequately protect
5 information the parties are entitled to keep confidential, to ensure that the parties are
6 permitted reasonable necessary uses of such material in preparation for and in the
7 conduct of trial, to address their handling at the end of the litigation, and to serve the
8 ends of justice, a protective order for such information is justified in this matter. It is
9 the intent of the parties that information will not be designated as confidential for
10 tactical reasons and that nothing be so designated without a good faith belief that it has
11 been maintained in a confidential, non-public manner, and there is good cause why it
12 should not be part of the public record of this case.
13 2. DEFINITIONS
14 2.1 Action: Jose Jesus Avalos-Aviles, individually, and on behalf of other
15 members of the general public similarly situated, and as an aggrieved employee
16 pursuant to the Private Attorneys General Act (“PAGA”) v. Red Robin International,
17 Inc., a Nevada corporation; DOES 1 through 10, inclusive; Case No. 2:22-cv-01257-
18 DAD-DB.
19 2.2 Challenging Party: a Party or Nonparty that challenges the designation of
20 information or items under this Order.
21 2.3 “CONFIDENTIAL” Information or Items: information (regardless of how it
22 is generated, stored, or maintained) or tangible things that qualify for protection under
23 Federal Rule of Civil Procedure 26(c) and as specified above in the Good Cause
24 Statement.
25 2.4 Counsel: Outside Counsel of Record and In-House Counsel (as well as their
26 support staff).
27 2.5 Designating Party: a Party or Nonparty that designates information or items
1 that it produces in disclosures or in responses to discovery as “CONFIDENTIAL.”
2 2.6 Disclosure or Discovery Material: all items or information, regardless of the
3 medium or manner in which it is generated, stored, or maintained (including, among
4 other things, testimony, transcripts, and tangible things), that are produced or generated
5 in disclosures or responses to discovery in this matter.
6 2.7 Expert: a person with specialized knowledge or experience in a matter
7 pertinent to the litigation who has been retained by a Party or its counsel to serve as an
8 expert witness or as a consultant in this action.
9 2.8 In-House Counsel: attorneys who are employees of a Party to this Action. In-
10 House Counsel does not include Outside Counsel of Record or any other outside
11 counsel.
12 2.9 Nonparty: any natural person, partnership, corporation, association, or other
13 legal entity not named as a Party to this action.
14 2.10 Outside Counsel of Record: attorneys who are not employees of a Party to
15 this Action but are retained to represent or advise a Party and have appeared in this
16 Action on behalf of that Party or are affiliated with a law firm that has appeared on
17 behalf of that Party, including support staff.
18 2.11 Party: any Party to this Action, including all of its officers, directors,
19 employees, consultants, retained experts, and Outside Counsel of Record (and their
20 support staffs).
21 2.12 Producing Party: a Party or Nonparty that produces Disclosure or Discovery
22 Material in this Action.
23 2.13 Professional Vendors: persons or entities that provide litigation support
24 services (for example, photocopying, videotaping, translating, preparing exhibits or
25 demonstrations, and organizing, storing, or retrieving data in any form or medium) and
26 their employees and subcontractors.
27 2.14 Protected Material: any Disclosure or Discovery Material that is designated
1 as “CONFIDENTIAL.”
2 2.15 Receiving Party: a Party that receives Disclosure or Discovery Material from
3 a Producing Party.
4 3. SCOPE
5 The protections conferred by this Stipulation and Order cover not only Protected
6 Material (as defined above) but also (1) any information copied or extracted from
7 Protected Material; (2) all copies, excerpts, summaries, or compilations of Protected
8 Material; and (3) any testimony, conversations, or presentations by Parties or their
9 Counsel that might reveal Protected Material. Any use of Protected Material at trial
10 will be governed by a separate agreement or the orders of the trial judge. This Order
11 does not govern the use of Protected Material at trial.
12 4. DURATION
13 Even after final disposition of this litigation, the confidentiality obligations
14 imposed by this Order will remain in effect until a Designating Party agrees otherwise
15 in writing or a court order otherwise directs. Final disposition is the later of (1) dismissal
16 of all claims and defenses in this Action, with or without prejudice, or (2) final judgment
17 after the completion and exhaustion of all appeals, re-hearings, remands, trials, or
18 reviews of this Action, including the time limits for filing any motions or applications
19 for extension of time under applicable law.
20 5. DESIGNATING PROTECTED MATERIAL
21 5.1 Each Party or Nonparty that designates information or items for protection
22 under this Order must take care to limit any such designation to specific material that
23 qualifies under the appropriate standards. The Designating Party must designate for
24 protection only those parts of material, documents, items, or oral or written
25 communications that qualify so that other portions of the material, documents, items, or
26 communications for which protection is not warranted are not swept unjustifiably
27 within the ambit of this Order. Mass, indiscriminate, or routinized designations are
1 prohibited. Designations that are shown to be clearly unjustified or that have been made
2 for an improper purpose (for example, to unnecessarily encumber the case-development
3 process or to impose unnecessary expenses and burdens on other parties) may expose
4 the Designating Party to sanctions. If it comes to a Designating Party’s attention that
5 information or items it designated for protection do not qualify for that level of
6 protection, that Designating Party must promptly notify all other Parties that it is
7 withdrawing the inapplicable designation.
8 5.2 Except as otherwise provided in this Order, Disclosure or Discovery Material
9 that qualifies for protection under this Order must be clearly so designated before the
10 material is disclosed or produced. Designation in conformity with this Order requires
11 the following:
12 (a) for information in documentary form (for example, paper or electronic
13 documents but excluding transcripts of depositions or other pretrial or trial
14 proceedings), the Producing Party must affix at a minimum the legend
15 “CONFIDENTIAL” to each page that contains Protected Material. If only a portion or
16 portions of the material on a page qualify for protection, the Producing Party must
17 clearly identify the protected portion(s) (for example, by making appropriate markings
18 in the margins).
19 A Party or Nonparty that makes original documents or materials available for
20 inspection need not designate them for protection until after the inspecting Party has
21 indicated which documents it would like copied and produced. During the inspection
22 and before the designation, all material made available for inspection must be treated
23 as “CONFIDENTIAL.” After the inspecting Party has identified the documents it wants
24 copied and produced, the Producing Party must determine which documents, or portions
25 thereof, qualify for protection under this Order. Then, before producing the
26 specified documents, the Producing Party must affix the “CONFIDENTIAL” legend to
27 each page that contains Protected Material. If only a portion or portions of the material
1 on a page qualify for protection, the Producing Party also must clearly identify the
2 protected portion(s) (for example, by making appropriate markings in the margins).
3 (b) for testimony given in depositions or in other pretrial or trial proceedings, the
4 Designating Party must identify the Disclosure or Discovery Material that is protected
5 on the record, before the close of the deposition, or by notifying the other party in
6 writing that the material is protected within 30 days of receiving the transcript of the
7 deposition.
8 (c) for information produced in some form other than documentary and for any
9 other tangible items, the Producing Party must affix in a prominent place on the exterior
10 of the container or containers in which the information is stored the legend
11 “CONFIDENTIAL.” If only a portion or portions of the information warrant protection,
12 the Producing Party, to the extent practicable, must identify the protected portion(s).
13 5.3 If timely corrected, an inadvertent failure to designate qualified information
14 or items does not, standing alone, waive the Designating Party’s right to secure
15 protection under this Order for that material. On timely correction of a designation, the
16 Receiving Party must make reasonable efforts to assure that the material is treated in
17 accordance with the provisions of this Order.
18 6. CHALLENGING CONFIDENTIALITY DESIGNATIONS
19 6.1 Any Party or Nonparty may challenge a designation of confidentiality at any
20 time consistent with the Court’s scheduling order. Unless a prompt challenge to a
21 Designating Party’s confidentiality designation is necessary to avoid foreseeable,
22 substantial unfairness, unnecessary economic burdens, or a significant disruption or
23 delay of the litigation, a Party does not waive its right to challenge a confidentiality
24 designation by electing not to mount a challenge promptly after the original designation
25 is disclosed.
26 6.2 The burden of persuasion in any such proceeding is on the Designating Party.
27 Frivolous challenges, and those made for an improper purpose (for example, to harass
1 or impose unnecessary expenses and burdens on other parties), may expose the
2 Challenging Party to sanctions. Unless the Designating Party has waived or withdrawn
3 the confidentiality designation, all parties must continue to afford the material in
4 question the level of protection to which it is entitled under the Producing Party’s
5 designation until the Court rules on the challenge.
6 7. ACCESS TO AND USE OF PROTECTED MATERIAL
7 7.1 A Receiving Party may use Protected Material that is disclosed or produced
8 by another Party or by a Nonparty in connection with this Action only for prosecuting,
9 defending, or attempting to settle this Action. Such Protected Material may be disclosed
10 only to the categories of persons and under the conditions described in this Order. When
11 the Action has been terminated, a Receiving Party must comply with the provisions of
12 Section 13 below (FINAL DISPOSITION).
13 Protected Material must be stored and maintained by a Receiving Party at a
14 location and in a manner sufficiently secure to ensure that access is limited to the
15 persons authorized under this Order.
16 7.2 Unless otherwise ordered by the Court or permitted in writing by the
17 Designating Party, a Receiving Party may disclose any information or item designated
18 “CONFIDENTIAL” only to the following people:
19 (a) the Receiving Party’s Outside Counsel of Record in this Action, as well as
20 employees of that Outside Counsel of Record to whom it is reasonably necessary to
21 disclose the information for this Action;
22 (b) the officers, directors, and employees (including In-House Counsel) of the
23 Receiving Party to whom disclosure is reasonably necessary for this Action;
24 (c) Experts (as defined in this Order) of the Receiving Party to whom disclosure
25 is reasonably necessary for this Action and who have signed the “Acknowledgment and
26 Agreement to Be Bound” (Exhibit A);
27 (d) the Court and its personnel;
1 (e) court reporters and their staff;
2 (f) professional jury or trial consultants, mock jurors, and Professional Vendors
3 to whom disclosure is reasonably necessary for this Action and who have signed the
4 “Acknowledgment and Agreement to Be Bound” (Exhibit A);
5 (g) the author or recipient of a document containing the information or a
6 custodian or other person who otherwise possessed or knew the information;
7 (h) during their depositions, witnesses and attorneys for witnesses to whom
8 disclosure is reasonably necessary, provided that the deposing party requests that the
9 witness sign the form attached as Exhibit A hereto and the witnesses will not be
10 permitted to keep any confidential information unless they sign the form, unless
11 otherwise agreed by the Designating Party or ordered by the Court. Pages of transcribed
12 deposition testimony or exhibits to depositions that reveal Protected Material may be
13 separately bound by the court reporter and may not be disclosed to anyone except as
14 permitted under this Order; and
15 (i) any mediator or settlement officer, and their supporting personnel, mutually
16 agreed on by any of the Parties engaged in settlement discussions or appointed by the
17 Court.
18 8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED
19 IN OTHER LITIGATION
20 If a Party is served with a subpoena or a court order issued in other litigation that
21 compels disclosure of any information or items designated in this Action as
22 “CONFIDENTIAL,” that Party must
23 (a) promptly notify in writing the Designating Party. Such notification must
24 include a copy of the subpoena or court order unless prohibited by law;
25 (b) promptly notify in writing the party who caused the subpoena or order to issue
26 in the other litigation that some or all of the material covered by the subpoena or order
27 is subject to this Protective Order. Such notification must include a copy of this Order;
1 and
2 (c) cooperate with respect to all reasonable procedures sought to be pursued by
3 the Designating Party whose Protected Material may be affected.
4 If the Designating Party timely seeks a protective order, the Party served with the
5 subpoena or court order should not produce any information designated in this action
6 as “CONFIDENTIAL” before a determination on the protective-order request by the
7 relevant court unless the Party has obtained the Designating Party’s permission. The
8 Designating Party bears the burden and expense of seeking protection of its Confidential
9 Material, and nothing in these provisions should be construed as authorizing or
10 encouraging a Receiving Party in this Action to disobey a lawful directive from another
11 court.
12 9. A NONPARTY’S PROTECTED MATERIAL SOUGHT TO BE
13 PRODUCED IN THIS LITIGATION
14 (a) The terms of this Order are applicable to information produced by a Nonparty
15 in this Action and designated as “CONFIDENTIAL.” Such information is protected by
16 the remedies and relief provided by this Order. Nothing in these provisions should be
17 construed as prohibiting a Nonparty from seeking additional protections.
18 (b) In the event that a Party is required by a valid discovery request to produce a
19 Nonparty’s Confidential Information in its possession and the Party is subject to an
20 agreement with the Nonparty not to produce the Nonparty’s Confidential Information,
21 then the Party must:
22 (1) promptly notify in writing the Requesting Party and the Nonparty that
23 some or all of the information requested is subject to a confidentiality agreement with
24 a Nonparty;
25 (2) promptly provide the Nonparty with a copy of this Order, the relevant
26 discovery request(s), and a reasonably specific description of the information requested;
27 and
1 (3) make the information requested available for inspection by the
2 Nonparty, if requested.
3 (c) If the Nonparty fails to seek a protective order within 14 days of receiving the
4 notice and accompanying information, the Receiving Party may produce the Nonparty’s
5 Confidential Information responsive to the discovery request. If the Nonparty timely
6 seeks a protective order, the Receiving Party must not produce any information in its
7 possession or control that is subject to the confidentiality agreement with the Nonparty
8 before a ruling on the protective-order request. Absent a court order to the contrary, the
9 Nonparty must bear the burden and expense of seeking protection of its Protected
10 Material.
11 10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL
12 If a Receiving Party learns that by inadvertence or otherwise, it has disclosed
13 Protected Material to any person or in any circumstance not authorized under this Order,
14 the Receiving Party must immediately notify the Designating Party in writing of the
15 unauthorized disclosures; use its best efforts to retrieve all unauthorized copies of the
16 Protected Material; inform the person or persons to whom unauthorized disclosures
17 were made of the terms of this Order; and ask that person or persons to execute the
18 “Acknowledgment and Agreement to Be Bound” that is attached hereto as Exhibit A.
19 11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE
20 PROTECTED MATERIAL
21 When a Producing Party gives notice to Receiving Parties that certain
22 inadvertently produced material is subject to a claim of privilege or other protection,
23 the obligations of the Receiving Parties are those set forth in Federal Rule of Civil
24 Procedure 26(b)(5)(B). This provision is not intended to modify whatever procedure
25 may be established in an e-discovery order that provides for production without prior
26 privilege review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the
27 parties reach an agreement on the effect of disclosure of a communication or
1 information covered by the attorney-client privilege or work product protection, the
2 parties may incorporate their agreement in the stipulated protective order submitted to
3 the court.
4 12. MISCELLANEOUS
5 12.1 Nothing in this Order abridges the right of any person to seek its
6 modification by the Court.
7 12.2 By stipulating to the entry of this Order, no Party waives any right it
8 otherwise would have to object to disclosing or producing any information or item on
9 any ground not addressed in this Order. Similarly, no Party waives any right to object
10 on any ground to use in evidence of any of the material covered by this Order.
11 12.3 A Party that seeks to file under seal any Protected Material must comply
12 with Civil Local Rule 141. Protected Material may be filed under seal only pursuant to
13 a court order authorizing the sealing of the specific Protected Material at issue. If a
14 Party's request to file Protected Material under seal is denied, then the Receiving Party
15 may file the information in the public record unless otherwise instructed by the Court.
16 13. FINAL DISPOSITION
17 After the final disposition of this Action, as defined in paragraph 4, within 60
18 days of a written request by the Designating Party, each Receiving Party must return all
19 Protected Material to the Producing Party or destroy such material. As used in this
20 subdivision, “all Protected Material” includes all copies, abstracts, compilations,
21 summaries, and any other format reproducing or capturing any of the Protected
22 Material. Whether the Protected Material is returned or destroyed, the Receiving Party
23 must submit a written certification to the Producing Party (and, if not the same person
24 or entity, to the Designating Party) by the 60-day deadline that identifies (by category,
25 when appropriate) all the Protected Material that was returned or destroyed and affirms
26 that the Receiving Party has not retained any copies, abstracts, compilations,
27 summaries, or any other format reproducing or capturing any of the Protected Material.
1 Notwithstanding this provision, Counsel are entitled to retain an archival copy of all
2 pleadings; motion papers; trial, deposition, and hearing transcripts; legal memoranda;
3 correspondence; deposition and trial exhibits; expert reports; attorney work product;
4 and consultant and expert work product even if such materials contain Protected
5 Material. Any such archival copies that contain or constitute Protected Material remain
6 subject to this Order as set forth in Section 4 (DURATION).
7 14. SANCTIONS
8 Any willful violation of this Order may be punished by civil or criminal
9 contempt, financial or evidentiary sanctions, reference to disciplinary authorities, or
10 other appropriate action at the discretion of the Court.
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Date: February 7, 2023 CAPSTONE LAW APC
1
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By:_/s/ Roxanna Tabatabaeepour
3
Orlando Villalba
4 Helga Hakimi
Roxanna Tabatabaeepour
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6 Attorney for Plaintiff,
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Dated: February 17, 2023 JACKSON LEWIS P.C.
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12 By: /s/ Martin P. Vigodnier
Adam Y. Siegel
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Martin P. Vigodnier
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Attorneys for Defendant
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RED ROBIN INTERNATIONAL,
16 INC.
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1 ORDER
2 IT IS HEREBY ORDERED that the parties’ stipulation is granted.
3 IT IS FURTHER ORDERED THAT:
4 1. Requests to seal documents shall be made by motion before the same judge who will
5 decide the matter related to that request to seal.
6 2. The designation of documents (including transcripts of testimony) as confidential
7 pursuant to this order does not automatically entitle the parties to file such a document with the
8 court under seal. Parties are advised that any request to seal documents in this district is governed
9 by Local Rule 141. In brief, Local Rule 141 provides that documents may only be sealed by a
10 written order of the court after a specific request to seal has been made. L.R. 141(a). However, a
11 mere request to seal is not enough under the local rules. In particular, Local Rule 141(b) requires
12 that “[t]he ‘Request to Seal Documents’ shall set forth the statutory or other authority for sealing,
13 the requested duration, the identity, by name or category, of persons to be permitted access to the
14 document, and all relevant information.” L.R. 141(b).
15 3. A request to seal material must normally meet the high threshold of showing that
16 “compelling reasons” support secrecy; however, where the material is, at most, “tangentially
17 related” to the merits of a case, the request to seal may be granted on a showing of “good cause.”
18 Ctr. for Auto Safety v. Chrysler Grp., LLC, 809 F.3d 1092, 1096-1102 (9th Cir. 2016); Kamakana
19 v. City and County of Honolulu, 447 F.3d 1172, 1178-80 (9th Cir. 2006).
20 4. Nothing in this order shall limit the testimony of parties or non-parties, or the use of
21 certain documents, at any court hearing or trial – such determinations will only be made by the
22 court at the hearing or trial, or upon an appropriate motion.
23 5. With respect to motions regarding any disputes concerning this protective order which
24 the parties cannot informally resolve, the parties shall follow the procedures outlined in Local
25 Rule 251. Absent a showing of good cause, the court will not hear discovery disputes on an ex
26 parte basis or on shortened time.
27 ////
1 6. The parties may not modify the terms of this Protective Order without the court’s
2 approval. If the parties agree to a potential modification, they shall submit a stipulation and
3 proposed order for the court’s consideration.
4 7. Pursuant to Local Rule 141.1(f), the court will not retain jurisdiction over enforcement
5 of the terms of this Protective Order after the action is terminated.
6 8. Any provision in the parties’ stipulation that is in conflict with anything in this order is
7 hereby DISAPPROVED.
8 DATED: February 17, 2023 /s/ DEBORAH BARNES
UNITED STATES MAGISTRATE JUDGE
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1 EXHIBIT A
2 ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND
3 I, _____________________________ [print or type full name], of
4 _________________ [print or type full address], declare under penalty of perjury that
5 I have read in its entirety and understand the Stipulated Protective Order that was
6 issued by the United States District Court for the Eastern District of California on
7 [date] in the case of Jose Jesus Avalos-Aviles, v. Red Robin International, Inc. Case
8 No. 2:22-cv-01257-DAD-DB. I agree to comply with and to be bound by all the terms
9 of this Stipulated Protective Order and I understand and acknowledge that failure to so
10 comply could expose me to sanctions and punishment in the nature of contempt. I
11 solemnly promise that I will not disclose in any manner any information or item that is
12 subject to this Stipulated Protective Order to any person or entity except in strict
13 compliance with the provisions of this Order.
14 I further agree to submit to the jurisdiction of the United States District Court
15 for the Eastern District of California for the purpose of enforcing the terms of this
16 Stipulated Protective Order, even if such enforcement proceedings occur after
17 termination of this action.
18 I hereby appoint __________________________ [print or type full name] of
19 _______________________________________ [print or type full address and
20 telephone number] as my California agent for service of process in connection with
21 this action or any proceedings related to enforcement of this Stipulated Protective
22 Order.
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24 Date: ______________________________________
25 City and State where sworn and signed: _________________________________
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1 Printed name: _______________________________
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3 Signature: __________________________________
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