Attachment 1 (Accessible PDF).pdf

ETA Advisory File Text

U.S . Depa rtm ent of Labor Em ployment and Tra ining Adm inistration Form ETA 9177 OMB Control No. 1205 - 0527 Expira tion Da te 07 31 2026 Attachment I-1 ATTACHMENT I Unemployment Insurance UI Information Technology IT Modernization Pre-Implementation Planning Checklist Report Version 1 U.S. Department of Labor Employment and Training Administration Form ETA 9177 U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -2 UI IT Modernization Pre -Implementation Planning Checklist Report State Name Date of Submission Project Name Scheduled Go Live Date Contact Information Name Title Address Phone Number . Email Address Summary of Project U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -1 U nemployment Insurance UI Information Technology IT Modernization Pre - Implementation Planning Checklist Version 1 1. Functionality and Workarounds Ensure all f unctionalities are fully available and operational pref erably with no high or critical def ects . If a functionality is not f ully available an interim workaround should be in place with a plan to quickly f ix the defects especially ones that are deemed high or critical . W orkarounds should be minimized f ully tested and exercised with the staf f for any system f unctionality that is def erred or necessary to address known system issues. 1.1. All Benef it f unctions have been f ully tested including all service channels such as web mobile telephone etc. and are f ully operational unless work around s have been planned f or and tested including but not limited to 1.1.1. Claims Filing For all supported programs Regular UI Unemployment Compensation f or Federal Employees Unemployment Compensation f or Ex -Servicemembers Combined Wage Claim Disaster Unemployment Assistance Trade Readjustment Allowances any extensions etc. 1.1.2. Monetary determinations and monetary re -determinations 1.1.3. Non -monetary determinations Separation and non -separation issues including automated holds are f lag ged f or adjudication. The e f f ects across Benef its Year Beginnings especially involving converted claims claims migrated f rom the legacy to the new system and Benef it Charging non -monetary scheduling of issues as applicable have been thoroughly tested 1.1.4. Continued Claims processing 1.1.5. Benef it payment mechanisms including as applicable direct deposit debit card and checks 1.1.6. Benef it Payment Control f unctions and other processes associated with prevention detection and recovery of improper and f raudulent payments and 1.1.7. Claimant account portals and or maintenance including password reset f unctionality as applicable 1.2. All Tax f unctions have been f ully tested unless work around s have been planned f or and tested including but not limited to 1.2.1. Employer Registration U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -2 Initial registration and Updates to Employer Registration 1.2.2. Employer liability determinations including reimbursable employers and employer status change 1.2.3. Employer audit 1.2.4. Tax rate computation 1.2.5. Employer delinquency enf orcement 1.2.6. Employer tax and wage report and input processing 1.2.7. Tax collections 1.2.8. Tax ref unds overpayments 1.2.9. New business registration and 1.2.10. Quarterly tax f iling data entry 1.3. All Appeals f unctions such as automated f iling of appeals hearing notices hearing decision correspondence etc. have been f ully tested 1.4. All Reporting f unctions have been f ully tested unless work around s planned f or and tested including but not limited to 1.4.1. Federal reporting f unctions including UI Required Reports Benef its Accuracy Measurement and UI D ata Validation and 1.4.2. UI program management reporting f unctions such as tracking of initial and continued claims by age management dashboard and ad hoc and system logging reports 1.5. All Interf aces external and internal have been f ully tested unless work around s have been planned f or and tested including but not limited to 1.5.1. Interf aces with call center operations e.g. screen pop Interactive Voice Response IVR . Recovery procedures are established and proven in the event that an interface is down f ails 1.5.2. UI Interstate Connection ICON network interf aces including Social Security Administration cross -match 1.5.3. Treasury Of f set Program interf ace with the Internal Revenue Service U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -3 1.5.4. Connectivity with the UI Integrity Center s Integrity Data Hub 1.5.5. National Directory of New Hires interf ace with Department of Health and Human Services 1.5.6. State Inf ormation Data Exchange System interf ace with Employers and 1.5.7. Other external interfaces and extracts such as those required to retrieve wage record data and quarterly employment and wages statistics Quarterly Census of Employment and Wages QCEW Local Area Unemployment Statistics LAUS and Longitudinal Employer -Household Dynamics microdata and automatic cross matches f or identity or other integrity purposes 1.6. All Testing has been completed including but not limited to 1.6.1. System generated f orms and correspondence have been f ully tested including any conf igurability mechanisms and multiple language implementations 1.6.2. All user roles have been tested and users with appropriate permissions can easily change staf f role assignments directly in the application 1.6.3. Printing processes have been f ully tested including Verif ication of printer tap test requirements have been met including cartridge nozzle perf ormance and printer internal f irmware f unctionality Verif ication of a process in place to do manual intervention f or letters and payments and Verif ication of mailing address es and proper display of United States Postal Service barcodes in window envelopes multiple pages per envelope are possible and that printers can handle duplex printing conservation of resources 1.6.4. Imaging and scanning as needed have been f ully tested . Suf f icient storage capacity has been provisioned All legacy system image f iles have been successf ully migrated as applicable Indexing has been tested and validated Optical Character Recognition has been tested and validated as applicable and Imaging system recovery f r om failure has been tested to ensure critical customer services are not impacted 1.6.5. Batch Processes including execution timelines have been f ully tested as outlined below U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -4 Batch process es have been executed f or at least a week to ensure that all links are pointing to the correct places all jobs run as expected and produce expected results Batch processing should be completed within a designated amount of time Batch processing remediation and recovery of f ailures have been tested and validated Weekly monthly quarterly and annual batch process have been tested and validated If possible a mock execution has been conducted by states f or at least a week with manuf actured data to simulate three times the expected l oad in order to ensure system readiness Time travel aging test data has been incorporated as part of system testing and User Acceptance Testing UAT If the testing can be done in an enterprise test environment production like interaction between systems via interfaces and web services has been simulated to provide insight into potential bott lenecks or issues bef ore launch and Af ter testing e nsure that any environment conf iguration f ile s have been updated f or production 1.6.6. Pilot the process during f inal testing f or reporting system issues 1.7. Workf lows have been verif ied and adjusted by c onduct ing thorough review of system -generated issue f lags triggers to ensure they are necessary and are not creating f alse issues. This ef f ort should include 1.7.1. Monitor ing workf low work items in new system and ensure proper staf f coverage on all queues 1.7.2. Ensuri ng the capability to either migrate work items or have a process to identif y unprocessed semi processed work on the new system and 1.7.3. Addressing and closing as many work items as possible across all f unctions bef ore go -live 1.8. System issue handling processes have been established practiced before go -live and are in operation in order to 1.8.1. Ensure processes are in place to identif y track and address system errors 1.8.2. Develop procedures to document and communicate any system work -around or resolution and 1.8.3. Ensure system error messages are understandable and have been f ully tested bef ore go -live . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -5 2. External Alternate Access Options and Usability Issues Addressed 2.1. Alternative Access Options are made available in compliance with ETA guidance including alternative access options for individuals with barriers to f iling by phone or on - line such as those with Limited English Prof iciency disabilities literacy issues including computer literacy and computer access issues 2.2. Websites and other f orms of communications like brochures and posters are in place which clearly identif y alternative access points that ef f ectively communicate to the population s with barriers described in section 2.1 2.3. All staf f have been f ully trained on how to assist individuals with access barriers on using alternative f iling options 2.4. Staf f and customer system access to new system has been def ined with outreach to all customers regarding access changes prior to going live including processes to migrate existing credentials and or establish new credentials 2.5. New credentials are clearly described to the customer when attempting to f irst access the new system. If security questions or knowledge base authentications are used f or self -services industry best practices should be f ollowed. If email accounts are used as the UserID f or self -services login the state has provided mechanisms f or customers to easily create an email account if they do not have one and 2.6. Ensure usability and access including 2.6.1. Compliance with the Americans with Disabilities Act including meeting 508 compliance standards f or hardware sof tware websites and documentation 2.6.2. Website content has been translated for identified signif icant population language groups within the state including correspondence as applicable 2.6.3. Relevant state standards and other standards such as Web Content Accessibility Guidelines have been incorporated 2.6.4. On -line content is clear understandable and at appropriate reading level pref erably tested by appropriate customer population 2.6.5. Websites provide inf ormation on alternative access f or individuals with barriers and 2.6.6. IVR phraseology and messages are clear and understandable. U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -6 3. Policies and Procedures Ensure policies and p rocedures have been d evelop ed completed and disseminat ed including 3.1. Policy and procedural changes coinciding with UI system modernization 3.2. Policies f or data security including those f or handling privacy and conf idential data 3.3. Policies f or data retention and data disposal 3.4. Staf f has been f ully trained on new policies and procedures 3.5. Any updates to organizational structure have been coordinated with human resources department and disseminated agency -wide 3.6. Any new or modif ied roles have been clearly def ined and staf f have been appropriately trained and 3.7. Disaster Recover y DR plan is in place and the Recovery Time Objective and Recovery Point Objective have been esta blished and disse minated. U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -7 4. Technical Preparation f or System Implementation Ensure the t echnical preparation for system implementation is completed prior to go -live including 4.1. Data architectures data structures have been addressed and documented. Internal and external data users have been consulted in the development of new data structures 4.2. Data conversion is complete and successf ul including 4.2.1. State policies and procedures have been f ollowed to inf orm migration strategy of data to the new system and backlogs are addressed prior to initiating data migrat ion process 4.2.2. Data model diagram entity relationship model of the legacy system and the new system have been completed 4.2.3. System design document s technical design document s and relate d artif acts have been completed and reviewed f or completeness 4.2.4. New system results checked and reconciled against legacy system results 4.2.5. Spot check s have been completed f or particular areas of interest such as overpayments certif ications employer charging ICON Billing IB6 and accounting balances 4.2.6. System blackout period has been benchmarked if appropriate with notif ication and messaging to customers in advance 4.2.7. M ultip le successf ul data conversions including record count verif ications and Extract Transf orm Load f inal load benchmarking have been completed and process lockdown is in place b ef ore go ing live and 4.2.8. Financial r eporting has been thoroughly tested and validated as T rust Fund Financial staf f interactions are critical 4.3. Independent Verif ication and Validation has been conducted as needed 4.4. Bridging processes protocols between applications systems are in place as needed f or example new benef its system integrated with legacy tax system or the inverse 4.5. User roles have been well -defined conf igured and set -up in the system. The use of excessive amount of roles in the system should be avoided in order to ensure a coordinated workf low process 4.6. Comprehensive UAT has been perf ormed including U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -8 4.6.1. UAT has been c onducted with positive results and conducted again f ollowing any additional system changes 4.6.2. System def ects were systematically tracked and remedied 4.6.3. Def ect tracking and remediation processes are in place post go -live in conjunction with development vendor along with applicable service level agreements SLAs f or response times and f ix turnaround times 4.6.4. System help has been verif ied e.g. page level f ield level and 4.6.5. Logging and exception handling have been verif ied including any tool used for mining application logs 4.7. Capacity has been developed to rapidly identify system f laws and make immediate f ixes . Hot f ix procedures are established exercised and validated 4.8. Contingency Back -up plan is in place if new system f ails particularly if no overlap of legacy and new system at go live point 4.9. If a DR site is in place and available testing and validation of the DR site has been conducted 4.10. Incoming phone capacity lines and staff have been adjusted f or anticipated increases in call volume including 4.10.1. Call Centers as applicable and 4.10.2. Any other Agency unit staf f that will conduct triage of system issues with customers 4.11. Go -live decision points show stoppers have been outlined and continue to be f ollowed 4.12. System perf ormance has been checked under peak user loads including complex transactions prior to go -live 4.13. System availability testing has been conducted including 4.13.1. Demonstrated system availability under heavy loads f or sustained period of times and 4.13.2. Monitor ing of computing resource consumption processors memory input output etc. 4.14. System operations reporting is available including management dashboard ad hoc reports and system logging and audit trails as needed 4.15. Production conf iguration is def ined and in place U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -9 4.16. Automated production build testing production environment promotion process is in place f or post -deploy def ect f ixes and enhancements 4.17. System s ecurity has been tested and validated including 4.17.1. Verif ication and validation of Data and System s ecurity 4.17.2. Verif ication of other internal system controls in order to ensure security and conf identiality of data and 4.17.3. Security Penetration and or Perf ormance Testing has been conducted 4.18. Business knowledge has been successf ully transf erred to appropriate agency staf f to operate the system including role management conf iguration settings and management dashboards and reporting 4.19. End user support problem reporting and resolution protocols are in place 4.20. IT knowledge transf er has been completed in order f or agency to maintain and support the system . System perf ormance benchmarks documented during build and start early have been used by IT staf f to complete conf iguration programming changes to support perf ormance and system expectations not just help vendor and 4.21. Transition planning and execution concerning post -warranty or maintenance phase has been validated with vendor . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -10 5. Call Center Customer Service Operations Ensure Call Center Customer Service Operations strategies are in place including 5.1. Call center standard operational procedures adapted as appropriate 5.2. Call c enter staf f and or customer service representatives CSRs have been f ully trained including 5.2.1. CSRs agents have participated in system UAT 5.2.2. CSRs agents supervisors and managers have been trained in the use of the new system 5.2.3. Staf f have been c ross train ed f or use augmentation particularly to manage inquiries 5.2.4. Project staf f have been assigned embedded into the customer service operations f or at least the f irst f ew weeks in order to help the team transition to the new system support procedure and 5.2.5. Call center staf f have been included in the triage calls f or the f irst f ew weeks af ter go ing live 5.3. Modernization system and operations help desk inf ormation have been provided to all f ront -line CSR staf f 5.4. Front -line and management staff know triage process when system issue s arise and issue escalation processes have been clearly def ined and understood by staf f and 5.5. Team meetings are scheduled daily and as needed to address 5.5.1. New s ystem issues 5.5.2. Customer complaints and 5.5.3. New operational or procedural issues . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -11 6. Business Process Ensure new business processes have been established staf fed and that staf f have been f ully trained on any all n ew system operations 6.1. Business processes and standard operating procedures have been developed and made available to all staf f to enable them to understand how the new system has changed their work processes 6.2. Roles responsibilities have been f ully def ined prior to go -live 6.3. Staf f have been trained on new business process es and roles and responsibilities 6.4. Training materials and tools to support new business processes desk guides handbooks etc. have been f ully developed and provided to management and staf f . A f inal training session where practice on production work happens to uncover potential skill gaps and also possible conversion issues has been conducted 6.5. Service delivery strategies have been clearly identif ied made known to staf f and f ully communicated to customers 6.6. Management and staf f have been f ully trained on new system f eatures and operations broadly as well as in relation to their specif ic job responsibilities including 6.6.1. Training that covers ref resher inf o rmation on program knowledge 6.6.2. Training or ref resher training has been scheduled as close to go -live as possible and 6.6.3. Recognition that p eople learn at a dif f erent pace if the training material is online or interactive ensure the resources are made available to staf f f or self -learning af t er f ormal classes are complete 6.7. Additional staf f ing needs have been identif ied secured to address new system implementation including 6.7.1. Call c enter s calls can dramatically increase during a conversion 6.7.2. Adjudication s taf f modernized systems tend to contain more automated f lags that raise issues requiring adjudication 6.7.3. Appeals s taf f the number of appeals may increase following a conversion as a result of newly automated processes which may impact claimants benef its or employers liability 6.7.4. Other support f unctions such as integrity -related activities and U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -12 6.7.5. Advance i dentif ication and clarif ication of roles f or the members of the triage team e.g. Frontline and Management staf f Help Desk staf f Call Center staf f Vendor Labor Market Inf ormation LMI staf f etc. . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -13 7. Help Desk Ensure Staf f and Help Desk Support is available including 7.1. Key staf f have been put on alert and made available during critical times of conversion and deployment 7.2. Procedures have been established f or escalation processes triage processes f or addressing system technical f unctional issues communication channels and coordination with Call Centers as applicable 7.3. Dry -runs of procedures with Help Desk staf f have been conducted including 7.3.1. Project staf f have been embedded into the help desk team to help the team transition to support the new application and answer questions etc. and 7.3.2. Help desk staf f is included in the triage calls 7.4. Help Desk is adequately s taf f ed with modernization testers including 7.4.1. Subject Matter Experts Business Analysts and Project Team members 7.4.2. Subject M atter Experts have been assigned f or every 10 -15 people in the State Agency in order to assist with questions and training and 7.4.3. Laptops have been distributed to modernization testers Subject Matter Experts to report any f indings 7.5. Contact inf ormation has been published and disseminated to appropriate personnel including LMI staf f 7.6. Procedures to categorize and track system issues based on help request s are in place e.g. credential access issue perf ormance questio ns needing clarif ication etc. and 7.7. Ensure Help Desk is available to support staf f . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -14 8. Management Oversight Ensure m anagement ov ersight is delivered including 8.1. Managers have been f ully trained on management f eatures and reporting processes in the system including those f or LMI and Bureau of Labor Statistics BLS to ensure that state unemployment and employment statistics can continue to be provided to the state 8.2. Managers have been prepared to support staf f if system issues arise 8.3. Additional management meetings are scheduled during transition to identify and resolve issues and 8.4. A support group f or managers has been established to share inf ormation and relearn how to do their job f unctions using the new system . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -15 9. Vendor Support Communications Ensure v endor support and c ommunications has been established including 9.1. Process f or addressing post implementation system f ixes with vendor is in place prior to implementation 9.2. Process f or tracking system and post -implementation system issues is in place 9.3. Routine daily meetings with the vendor during transition has been scheduled to identif y and prioritize system issues f or as long as needed 9.4. Process is in place to track the implementation of def erred f unctionalities 9.5. The hand -off process f or identified incidents issues changes bugs to the vendor is clear and is understood by all parties 9.6. Systems are in place to track the post -implementation support criteria and SLAs def ined in the contract and 9.7. The triage process has active vendor engagement . U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -16 10. Communication Processes and Procedures Ensure c ommunications processes and procedures have been established including 10.1. Staf f Communications including 10.1.1. Both UI and non -UI staf f e.g. LMI staf f have been included in the communications throughout the project 10.1.2. Staf f have been f ully brief ed on implementation plan in addition to being f ully trained and 10.1.3. Staf f have been provided with clear instructions on how to handle system issues if they arise 10.2. Claimant and Employer Communications including 10.2.1. Employer and Claimant outreach regarding roll -out of new system 10.2.2. System go -live date disseminated 10.2.3. System black -out period if needed and methods of conduct ing business during this phase has been clearly communicated to staf f and customers 10.2.4. Agency contact inf ormation has been widely disseminated 10.2.5. System how -to inf ormation has been provided to staf f and customers and 10.2.6. Processes have been made available to support c ommunication with individuals with l imited English prof iciency and staf f are trained on these processes 10.3. Public Communications have been issued prior to go -live point as well as periodically during startup including 10.3.1. State stakeholders have been notified in advance i.e. Governor s of f ice Legislative Services and partner agencies 10.3.2. System go -live date has been disseminated 10.3.3. System black -out period if needed has been communicated 10.3.4. A plan has been established to address potential issues ad -hoc inquiries at the time of launch and 10.3.5. A plan has been put in place to handle the press media f or a successf ul launch as well as f or any unf oreseen issues causing the launch to not go as planned. U.S. Depa rtm ent of Labor OMB Control No. 1205-0527 Em ployment and Tra ining Adm inistration Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I-17 11. Labor Market Inf ormation LMI Federal Reporting Ensure LMI f ederal reporting f unctions have followed nationally standardized specif ications available at https www.bls.gov cew additional-resources unemployment-insurance- modernization home.htm tested validated within project timelines and are f ully operational including 11.1. LMI Notif ication 11.1.1. LMI has received advance notif ication of planning timetable f or benef its and tax portions of the system implementation milestones and 11.1.2. LMI has been notif ied of go-live dates f or benef its and tax systems 11.2. LMI Participation 11.2.1. Discussions have occurred with LMI regarding any planned changes to UI numbering schemes data sources or computations 11.2.2. Collaboration has occurred with LMI on data uses and def initions to help with the development specif ications Data dictionary mapping of the f ields in the legacy UI system to the f ields in the new system has been shared and discussed with LMI and Consultation with LMI on the def initions of employment and wages used in the new system 11.2.3. Any changes to the reporting responsibilities of employers have been developed in consultation with LMI and the outreach plan to employers has been shared with LMI 11.2.4. Periodic demonstrations of the parts of the system relevant to LMI have occurred as the new UI system progresses toward deployment with an opportunity f or LMI staf f to provide f eedback on screens as they are developed and prior to go-live 11.2.5. Testing schedule has been discussed and agreed upon with LMI staf f LMI staf f has been allowed to parallel test the new UI systems as it progresses toward deployment and an opportunity to provide f eedback on any identif ied issue and Issues identif ied by LMI during testing have been resolved prior to go-live 11.2.6. LMI has been granted the same level of access to the screens f orms etc. in the new system as they had in the legacy system 11.3. Data Exchange U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -18 11.3.2. Extracts have been tested by LMI staf f in order to ensure that it meets LMI requirements 11.4. Data Validation 11.4.1. Ensure LMI has completed data validation to produce LAUS and QCEW and 11.4.2. Ensure completion of LMI testing and validation of benef it claims data. U.S . Depa rtm e nt of L abor OMB Control No. 1205 -0527 Em ployment and Tra ining Adm inistratio n Expira tion Da te 07 31 2026 Form ETA 9177 Attachment I -19 Certification Certifying Official Name Title Signature Telephone Number Date Email Address