Sample lease contracts for private shops are commonly used.

If you rent a shop, you should sign a contract with the landlord to ensure your rights and interests. The following is a sample of private store lease contract that I compiled for you, for reference only. Welcome to read it.

Commonly used private store lease contract template (1) Lessor: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (hereinafter referred to as Party A)

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tel: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Lessee: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (hereinafter referred to as Party B)

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tel: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

On the basis of equality, voluntariness, mutual benefit and reciprocity, through consultation, Party A is willing to lease the house that it has the right to operate and manage to Party B, and both parties have reached the following agreement in accordance with relevant state regulations:

Rule number one. Basic information

Party A will lease the store (the subject of this contract) with the right to operate and sublease to Party B (No._ _ _ _ _ _ _ _).

Article 2. Date and method of payment of rent and deposit

1. The lease term is _ _ _ _ years, starting from _ _ _ _ _ _ _ _ _.

2. The first year's usage fee is RMB _ _ _ _ _ _ _ (in words: _ _ _ _ _ _), the second year's usage fee is RMB _ _ _ _ _ _ _ (in words: _ _ _ _ _ _ _), and the third year's usage fee is RMB _ _ _ _ _ _ _ _ _.

3. On the date of signing this contract, Party B shall pay the rental of RMB _ _ _ _ _ _ _ _.

Article 3. Payment methods of utilities, cleaning fees, telephone charges and maintenance fees.

1. Management fee, cleaning fee, water and electricity fee, telephone fee and broadband fee: Party B shall pay to the relevant departments by itself;

2. Maintenance costs: During the lease period, if Party B causes damage to the facilities related to the leased property, Party B shall be responsible for the maintenance costs, except for normal wear and tear.

Article 4. Change of Lessor and Lessee

2. During the lease period, if Party B wants to sublet the house to a third party, it must obtain the consent of Party A, pay all the expenses and go through the relevant formalities before the third party that has obtained the right to use becomes the natural party of this contract.

Article 5. Party B's responsibilities

1. Party B must pay the rent and other expenses according to the contract. In case of breach of contract, Party A has the right to charge Party B a late fee, which is _ _ _% of the rent and expenses actually owed every day. If it is overdue for _ _ _ days, Party A has the right to take back the house.

2. If Party B causes damage to the leased premises and its equipment, it shall be responsible for restoring it to its original state.

3. If Party B installs any instruments or machinery and special equipment exceeding the electronic load in the leased premises, it must obtain Party A's consent .. Party B shall be responsible for the accidents or fines caused by Party A's failure to go through relevant procedures, and compensate for the losses caused to the shops, safety facilities and fire-fighting facilities.

4. When the lease expires or the contract is terminated, Party B must deliver all the intact equipment and facilities in the leased house to Party A in a clean and intact state (except natural depreciation) on time.

5. If Party B has not moved after the lease expires or the contract is terminated, Party A has the right to move Party B's articles out of the store without undertaking the obligation of keeping them, and Party B has no right to demand compensation from Party A for losses.

6. Party B guarantees that the premises leased by Party A will be used as commercial premises, and that its legal operation conforms to the laws of People's Republic of China (PRC) and relevant government regulations. All legal liabilities and property losses caused by Party B's illegal operation shall be borne by Party B..

7. Party B shall abide by relevant national safety laws and regulations, and shall be responsible for all personal safety injuries caused by Party B's construction and operation during the lease period.

8. During the lease period, all taxes and fees incurred shall be borne by Party B. ..

Article 6. Party A's responsibilities (during the lease term)

1. Party A shall provide Party B with qualified leased premises and ensure that the water and electricity in the premises are connected.

2. Maintain the legitimate interests and management rights of Party B.. However, Party A shall not be responsible for the losses caused by theft and natural disasters.

3. Before Party B discloses its business nature and business type, Party A shall not disclose its business information at will.

Article 7. If the house leased by Party A needs to be rented at the expiration of the contract, under the same conditions, Party B has the priority to rent, and the way to increase the rent is determined by the market.

Article 8. During the lease period, if the leased house cannot be used due to natural disasters of force majeure, this contract can be terminated naturally, without mutual responsibility, and both parties can solve it through negotiation. If the leased premises cannot be used normally due to subjective reasons of Party A, Party A shall return the deposit and prepaid rent to Party B without interest.

Article 9. If there are any matters not covered in this contract, both parties shall supplement it according to the relevant provisions of People's Republic of China (PRC) Contract Law, and the supplementary terms have the same effect as this contract.

Article 10 Any dispute arising from the execution of this contract shall be settled by both parties through negotiation. If negotiation fails, it may be submitted to the administrative department for industry and commerce or the people's court for adjudication.

Article 11 During the lease period, Party B shall bear the legal responsibilities and consequences caused by its illegal acts.

Article 12 This contract shall come into effect after being signed and sealed by both parties. The original of this contract is in duplicate, and each party holds one copy.

Party A: _ _ _ _ _ _ _ _ _ _ _ Party B: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Representative: _ _ _ _ _ _ _ _ _ _ Representative: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Phone number: _ _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ _ _ Phone number

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Model Lease Contract for Private Stores (II) Party A: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Party B: _ _ _ _ _ _ _ _ _ _ _

Through negotiation, Party A and Party B reach the following contract:

1. Party A rents out two facade rooms on the first floor of _ _ _ _ _ _ to Party B for use.

Second, the rent and mode of delivery

The annual rent is RMB 10,000 Yuan only, and Party B shall pay the annual rent for the first year from the effective date of this contract (before 1 month 3 1 year).

Third, the lease term.

_ _ _ years, from _ _ _ _ _ _ _ February 1 day to _ _ _ _ _ _ _ year 1 month 3 1 day.

4. Party B rents the facade room for catering business. During the operation period, Party B shall not change the theme structure of the house without authorization, and shall not sublet it to others without Party A's permission.

5. If Party B does not manage well during the operation period, with the consent of Party A, it can transfer the store to another party, and all the decoration of Party B can be transferred to the other party by itself, and the transfer time shall not exceed the contract period of this contract. If Party B needs to continue the operation after the expiration of three years, under the same conditions, Party B has the priority to lease. If Party B stops renewing the lease or terminates the contract in advance, all the decoration of Party B will be left to Party A unconditionally, and the lease fee paid by Party B to Party A in advance during the early termination of the contract will not be refunded.

6. During the term of this contract, Party A shall not take back the house without reason, otherwise it shall compensate Party B for reasonable losses.

Seven. Matters not covered in this contract shall be settled by both parties through consultation.

Eight. This contract shall come into effect after being signed by both parties.

Party A: _ _ _ _ _ _ _ _ _ _ _ Party B: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Phone number: _ _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ _ _ Phone number

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Model Lease Contract for Private Stores (III) Lessor (hereinafter referred to as Party A): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Lessee (hereinafter referred to as Party B): _ _ _ _ _ _ _ _ _ _ _

Based on the principles of honesty, credit and mutual benefit, Party A and Party B have reached this contract on matters related to Party B's lease of Party A's house in accordance with the provisions of the Contract Law of People's Republic of China (PRC), for mutual compliance:

Rule number one. Location, address and shop area of the leased house

Store address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. The area of the store is about _ _ _ _ _ square meters.

Article 2. Use of lease

Store use

Article 3. lease term

1. The lease term is five years: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

2. Renewal: After the lease expires, if Party A agrees that Party B will continue to lease the house under this contract, the rent during the renewal period shall be determined by both parties through consultation according to the current market price. Under the same conditions, Party B enjoys priority. Unless otherwise agreed by both parties, the rights and obligations of both parties during the renewal period shall be implemented according to the corresponding provisions of this contract.

Article 4. Rent, payment method and payment term

1. Lease amount: _ _ _ _ _ _ yuan per year.

2. Payment method: payment. Party A and Party B shall pay the annual rent to Party A in one lump sum from the date of signing this contract, and the rent for the second to fifth years shall be paid one month in advance.

3. Party B must pay the rent to Party A as agreed. Failure to pay at maturity is regarded as breach of contract, and the penalty is RMB 100,000 only.

Fifth, the ancillary facilities and expenses of the house.

1. Party B shall pay direct expenses such as water, electricity, real estate and land use tax to Party A or a third-party property management company when using the facilities in the leased area. The charging standard shall be implemented in accordance with the relevant standards of _ _ _ _.

2. All other expenses arising from the commercial activities of the house shall be paid by Party B (including the expenses for Party B to apply for installing telephone, broadband, cable TV and other equipment).

3. During the lease period, Party B damages the quality of the leased house or the facilities inside and outside the house, including internal and external waterproofing, doors and windows, water and electricity, etc. The maintenance expenses shall be borne by Party B. ..

Sixth, the lease period of house repair.

1. After the lessor's house is delivered to the lessee for use, the lessee shall be responsible for the decoration and repair during the use period. If the lessee no longer uses the leased house, it shall not destroy the renovated fixed facilities and housing framework.

2. When the lessee needs to change the original appearance or main structure of the house during the renovation process, it needs to apply to Party A, and the construction can only be started after the approval of Party A's leadership and relevant departments. Construction units need qualified units, and put them on record in relevant departments. Anything that happens during and after the construction has nothing to do with Party A. If the construction is carried out without authorization, Party A has the right to terminate the contract in advance and compensate for the losses. The consequences shall be negotiated by both parties or handed over to the legal department for legal responsibility.

Article 7. Rights and obligations of Party A

1. has the right to charge Party B rent and other expenses or overdue penalty according to the provisions of this contract.

2. Supervise Party B to use the house correctly, and ensure that all kinds of facilities inside and outside the house can be used normally when Party B enters the site.

3. Party A shall not bear the business risks and responsibilities of Party B. ..

4. Party B commits one of the following acts: subletting, transferring or lending the renovated house without authorization; The leased house is used for illegal business or activities, which harms the interests of the public or Party A; Party A has the right to terminate the contract in advance and claim compensation for the rent arrears. During the lease term, Party B may invite for lease or investment in some areas, and Party A shall not interfere with it for any reason.

5. Sign a separate fire safety agreement with Party B as an annex to this contract to supervise Party B's safe use of the house. If Party B is found to have potential safety hazards, it has the right to request rectification within a time limit.

6. When Party B goes through the industrial and commercial and tax formalities, Party A shall provide Party B with relevant certificates of the house.

7. Under the condition that Party B does not use water and electricity illegally, Party A shall ensure that the store uses water and electricity normally.

Article 8. Rights and obligations of Party B

1. Use the leased premises to carry out normal business activities according to the purpose of using the leased premises. Party A shall not interfere, but Party B shall not change the purpose without authorization.

2. Ensure fire safety. In case of personal and property damage caused by Party B's use of the house or Party B's decoration of the house, Party B shall bear all compensation responsibilities.

3. Pay the rent and other expenses.

4. Do not dismantle and change the building structure without authorization, and do not engage in illegal activities in the leased house.

5. If Party A and Party B cannot operate normally due to the other party's reasons during the operation, the responsible party shall bear all losses. And be responsible for compensating the losses.

Article 9. Liability for breach of contract and compensation measures for contract termination

1. If the leased property is damaged due to natural disasters of force majeure, and the lessee suffers any losses or cannot use the property, both parties shall not be responsible for each other and the contract shall be terminated.

2. If Party A and Party B terminate the contract or lease it to others in advance without violating this contract, it shall be regarded as a unilateral breach of contract and shall compensate the other party for all economic losses. And there is a penalty of one hundred thousand yuan.

Article 10 Settlement of disputes

In case of other disputes during the performance of this contract, both parties shall settle them through friendly negotiation. If negotiation fails, either party may bring a lawsuit to the people's court.

Article 11 If there are any matters not covered in this contract, Party A and Party B shall make supplementary provisions through consultation in accordance with the relevant provisions of People's Republic of China (PRC) Contract Law, and the supplementary provisions shall have the same effect as this contract.

Article 12 This contract shall come into effect after being signed and sealed by both parties. The Contract has _ _ _ pages in total, with _ _ _ pages in total.

Lessor (Seal): _ _ _ _ _ _ _ _ Lessee (Seal): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Legal representative (signature): _ _ _ _ _ Legal representative (signature): _ _ _ _ _ _ _ _ _

Phone number: _ _ _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ _ _ _ Phone number

Contact address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

ID number: _ _ _ _ _ _ _ _ _ _ _ ID number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Model Lease Contract for Private Stores (IV) Lessor (hereinafter referred to as Party A): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Lessee (hereinafter referred to as Party B): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Party A is willing to lease its own store to Party B. According to the relevant regulations of the state, both parties have reached an agreement through consultation to conclude this contract:

Rule number one. Basic information

The store leased by Party A is located at _ _ _ _ _ _ _ _ _ _ _ _

Article 2. leasehold

_ _ _ _ _ years, from _ _ _ _ _ _ _ _ years to _ _ _ _ _ _ _ _ _ years. Party A shall deliver the goods to the store within _ _ _ days after signing the contract. If Party A delays the delivery to the store, the lease period will be extended accordingly.

Article 3. Rent and terms and conditions of rent payment

1. The monthly rent is RMB _ _ _ _ _ _ _, and Party B pays the rent every _ _ _ months. Party B can pay the rent by cheque or cash. The contract rent includes tax. When Party A collects the rent from Party B, it must show the official invoice approved by the tax authorities, otherwise Party B has the right to refuse to pay the rent.

Party A's bank: _ _ _ _ _ _ _ _ _ _ _

Payee's name: _ _ _ _ _ _ _ _ _ _ _ _

Account number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. After signing this contract, Party B shall pay the monthly rent as the deposit. After the termination of the contract, Party A may refund the deposit to Party B after Party B has paid off the rent, utilities, gas and telephone charges. If Party B terminates the contract in advance, it will be deemed as breach of contract, and the deposit will not be refunded. If Party B causes damage to Party A's store and related equipment during the lease period, Party A has the right to deduct the maintenance and compensation fees from Party B's deposit, and Party B must make up the deficiency within seven days after receiving Party A's notice.

Article 4. Payment methods for utilities, management fees, telephone charges, cleaning fees and maintenance fees.

1. Management fee: Party A shall pay it to relevant departments by itself every month;

2. Water and electricity charges and gas charges: Party B shall pay the relevant departments by itself every month;

3. Telephone charges: Party B shall pay the relevant departments by itself.

4. Maintenance costs: During the lease period, if Party B causes damage to the facilities related to the quality of the store in the leased property, Party B shall be responsible for the maintenance costs; If the furniture and household appliances in the leased property are damaged, Party B shall be responsible for the maintenance costs. Except normal wear and tear.

Article 5. Change of Lessor and Lessee

1. During the lease period, if Party A transfers the ownership of real estate to a third party, it shall comply with the relevant national regulations on real estate transfer, and Party B's consent is not required. However, Party A shall notify Party B in writing two months in advance. After the ownership of real estate is transferred to a third party, the third party will become the natural Party A of this contract, enjoy the rights and undertake the obligations of the original Party A. ..

2. During the lease term, if Party B wants to sublet the leased store to a third party, it must obtain the written consent of Party A in advance. The third party that has obtained the right to use becomes the natural Party B of this contract, enjoying the rights of the original Party B and undertaking the obligations of Party B. ..

Article 6. Party B's responsibilities

1. Party B must pay the rent and other expenses as agreed. In case of unreasonable breach of contract, Party A has the right to charge Party B a late fee, and Party B shall pay Party A a late fee of% of the monthly rent for each day overdue. If the rent is in arrears for _ _ _ _ days, it will be regarded as a breach of contract, and Party A has the right to take back the store without returning the deposit to Party B. ..

2. Before the termination of this contract, Party A and Party B shall notify the other party in writing one month in advance whether to terminate this contract.

3. During the lease period, Party B must take reasonable preventive measures to protect the equipment and facilities in good condition (except natural depreciation) during the lease period. Party B shall not change the structure and use of the leased store without authorization. If it is really necessary to change the use, it must be approved by Party A. If Party B causes damage to the leased store and its equipment, it shall be responsible for restoring it to its original state. If Party B is not responsible for restoring the original state at the expiration of the lease term, Party A has the right to restore the original state by itself, and the expenses shall be deducted from Party B's deposit. Party B must make up the deficiency within seven days after receiving the notice from Party A..

4. If Party B installs any equipment, instruments or machinery that exceeds the load of electric meters in the leased store, it must obtain Party A's consent, and Party A shall assist Party B to go through the relevant procedures, and the expenses shall be borne by Party B. Party B shall be responsible for the accidents or fines caused by failing to go through the relevant procedures without Party A's consent.

5. Party B shall not attach any articles or paint or make any changes outside the leased store.

6. When the lease expires or the contract is terminated, Party B must deliver all the intact equipment and facilities in the leased store to Party A in a clean and good condition suitable for use (except natural depreciation) on time.

7. If Party B has not moved after the lease expires or the contract is terminated, Party A has the right to move Party B's articles out of the store where the lease relationship has been terminated, without undertaking the obligation of keeping them. Party A has the right to demand compensation from Party B for the expenses incurred therefrom, and has the right to sue.

8. Party B guarantees that the store leased by Party A will be used as commercial premises and operate legally in accordance with the laws and regulations of People's Republic of China (PRC) and relevant government regulations. Party B shall be responsible for the compensation for the joint losses caused to Party A by Party B's illegal operation.

9. Party A shall show Party B the original documents related to the leased store and give Party B a copy consistent with the original. Including the real estate license of the leased store, the ID card of the owner of the store and the lease permit. If any third party claims the right to the leased store, so that Party B cannot use the leased store, Party A shall compensate Party B for all the losses suffered.

During the lease term, Party A:

(1) Maintenance of facilities within the term of this contract, including _ _ _ _ _ _ _ _ _ _ _ _ _;

(2) Be responsible for the safety and management of the building or community to which the leased house belongs;

(3) Responsible for the structural maintenance of the leased store.

(4) Party A guarantees that the legal operation of Party B will not be disturbed during the term of this contract.

Article 7. If the store leased by Party A needs to be rented at the expiration of the contract, Party B has the preemptive right under the same conditions as those proposed by Party A to the third party (but the rent can be adjusted appropriately with the change of social price index).

Article 8 During the lease term, if Party B is unable to use the leased store due to force majeure natural disasters, Party B shall immediately notify Party A in writing. If both parties agree that the leased store is damaged and cannot be repaired due to force majeure natural disasters, this contract can be terminated naturally, and both parties are not responsible for each other. Party A shall return all the deposit and prepaid rent to Party B without interest. In case of government expropriation or demolition, all compensation shall be owned by Party A, but the compensation for business part (including but not limited to decoration compensation, resettlement compensation, relocation compensation, business loss, etc.). ) Party A shall pay Party B directly according to the standard of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

Article 9. The quantity, model and decoration standard of indoor appliances and furniture provided by Party A shall be subject to the attachment.

Article 10 If there are any matters not covered in this contract, both parties shall make supplementary provisions through consultation, which have the same effect as this contract.

Any dispute arising from the execution of this contract shall be settled by both parties through negotiation. If negotiation fails, either party may bring a lawsuit to the people's court with jurisdiction.

This contract shall come into effect after being signed and sealed by the representatives of both parties. The original of this contract is in duplicate, and each party holds one copy.

Lessor: _ _ _ _ _ _ _ _ _ _ Lessee: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Phone number: _ _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ Phone number: _ _ _ _ _ _ _ _ _ _ Phone number

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _