Name of Form s1

Certification of Equipment Demonstration The Ohio State University Facilities Operations and Development fod.osu.edu 400 Enarson Classroom Bldg, 2009 Millikin Rd, Columbus, Ohio 43210 Phone: 614-292-4458 Fax: 614-292-2539

Demonstration Date OSU Contract No. Demonstration Time Project Name Contractor Equipment Item or System Demonstrator Name Demonstrator Company

Observations and Comments (attach additional pages if necessary)

Owner Certification A/E As an authorized agent for the Owner, I certify that the equipment or system described above was operated in my presence and that its Name operating procedures were explained and demonstrated to my satisfaction. I acknowledge that a copy of the attendance sheet is attached. - - Signature Date Name - - Signature Date Construction Manager

Demonstrator Name - - - - Signature Date Signature Date

0370_Certifcate_Equipment_Demonstration.doc SAO-F320-03v0508, ADM-5807 Page 1 of 1