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Z Same as primary contact (default If no Information Is provided below, even if the box is not <br />checked). <br />Contact name' First Basil Last Dancy <br />Contact email address' bdancy@ircgov.corn <br />Street address" 1801 27th St. <br />City* Vero Beach <br />StatelProvince• FL <br />Postal code* 32960 -3388 - <br />(For U.S. addresses, please provide the zip + 4, e.g. xxxxx-xxxx) <br />Country" United States <br />Phone` 772-226-1256 <br />Language preference. Choose the language for notices. , English <br />❑ This contact is a third party (not the Enrolled Affiliate). Warning: This contact receives <br />personally identifiable information of the Customer and its Affiliates. <br />"Indicates required fields <br />c. Online Services Manager. This contact is authorized to manag%llhe Online Services ordered <br />under the Enrollment and (for applicable Online Services) tb':add:or!reassign Licenses and <br />step-up prior to a true -up order. xa <br />❑ Same as notices contact and Online Admiri(strator•(defauh.if ho..informatibn<fs provided <br />below, even if box is not checked) <br />Contact name': First Basil Last Daney <br />Contact email address' bdancyc@ircgov.Com <br />Phone` 772-226-1256 �' y <br />❑ This contact is from a third party organization, (not the entity).. Werriing: This contact receives <br />personally identifiable information of, the entity: <br />indicates required fields7. <br />a °- <br />- <br />d. Reseller Information, Reselldtcontact for this:Enrollment is: <br />Reseller company, name", SHI International Corti,,;, <br />Street address (PO' boxes will not be'aIccepted)? 290 Davidson Ave <br />City' Somerset <br />State/Province" NJ. _ <br />Postal code" 088737":. <br />Country'' United States`. r" <br />Contact name' Taylor Lea_z4 <br />4 <br />'Phone' 888-764-86$8 <br />Contact email address' rn8te m shi,co <br />indicates required fields <br />By signing below,,the.Resell r id tifie abonfir that all in rmation provided in this <br />Enrollment ls.correct. <br />Signature` V <br />Printed name" <br />Printe}��I <br />Date" �tl4r,�Q� <br />indicates required fields <br />Changing a Reseller. If Microsoft or the Reseller chooses to discontinue doing bush vit <br />each other, Enrolled Affiliate must choose a replacement Reseller. If Enrolled Affiliate or the <br />Reseller Intends to terminate their relationship, the Initiating party must notify Microsoft and the <br />F_A2016EnrGov(US)SLG(ENG)(Nov2o16) Page 9 of 10 <br />Document x20-10634 <br />