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<br />ATTACHMENT A <br />Pre-Acceptance Change Request Form <br />Client Name: <br />Change Request No.: Date Issued: <br />/ / <br />Basic Information <br />Date Requested: <br />/ / Requested By: Company Name: <br />Date Required: <br />/ / Phone: E-mail: <br />Application or System: ReleaseNersion: <br />IMPACT-- Additional Time Estimated: Additional Cost Estimated: <br />Synopsis of Requested Change: <br />Supporting Documentation Attached? [ ]Yes [ ] No <br />Project Manager Approvals <br />Client Manager: (NamelTitle) Phone Number: E-mail: <br />Client Signature: Date Authorized: <br />Project Manager: Phone Number: E-mail: <br />Project Manager Signature: Date Authorized: <br />Authorized Signatures <br />RTS Signature: Date: <br />Client Signature: Date: Client PO Number: <br />Statement of Work No. ORD-23171-EA2E5O <br />Relational Technology Solutions "RTS" -Proprietary <br />11 <br />6/23/09-/v-1.0 <br />