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0 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@iregov.com <br />Street address* 1841 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 r. <br />Language preference. Choose the language for notices.' . <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 manage,the Online Services ordered <br />under the Enrollment and (for applicable Online Services) to- add;or.,reassign Licenses and <br />step-up prior to a true -up order. <br />❑ Same as notices contact and Online Adminlstrator.(defautt_.tf no;informaUO><:js provided <br />below, even if box is not checked} <br />Contact name': First Basil Last Darcy ei r�� •� ',., � ' <br />Contact email address* bdancy@ircgovcom ^.k�' <br />Phone* 772-226-1256 <br />❑ This contact is from a third party organization (ntst the eiltityjL..lNatn1hg: This contact receives <br />personally identifiable. information oft <br />*indicates required frelds <br />T z <br />d. Reseller,inforn. Ras elter contact for this Enroilmeht is: <br />Reseller company,narne` SHI International Corp. <br />Street address (PQ boxes will not be a.ccepted)* 290 Davidson Ave <br />City* Somerset N- <br />StatelProvinceKHJ' <br />Postal code* 08873yar <br />^Coyntry• United'States`, <br />Contact name* Peter Armstrong,- <br />-Phone'- 888-764-8888 <br />Contact einall'addreas* ms e" <br />shi.coaof <br />* lndlcates required,fields <br />By signing beiovsr the,Res ler i ritTed rmsth@t all information provided In this <br />Enrollment is correct., " p <br />Signature" <br />Printed name* kC <br />Printed t�tlej f a <br />Date* `I <br />'indicates required fields <br />Changing a Reseller. if fAicrosoft or the Reseller chooses to discontinue doing business with <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 />EA201GEnrGov(US)SLG(ENG)(Nov241 fi) image 9 of 10 <br />DoamEM X20-10634 <br />