IN WITNESS WHEREOF
James A. Steele and {name} have duly affixed their signatures on this {input10:4} day of {input10:5}, {input10:6}.
Information Provider

James A. Steele
UNIT 204, 112 14TH Ave SE
Calgary, Alberta, Canada, T2G 1C7

WITNESS: signature
Coral P. Francis
WITNESS: printed name: