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ATTACHMENT A <br />Pre - Acceptance Change Request Form <br />Client Name: <br />Change Request No.: Date Issued. <br />Basic Information <br />Date Requested: <br />Requested By: <br />Company Name: <br />Date Required: <br />Phone: <br />E -mail: <br />Application or System: <br />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: (Name/iitle) <br />Phone Number: <br />E -mail: <br />Client Signature: <br />Date Authorized: <br />Project Manager: <br />Phone Number: <br />E -mail: <br />Project Manager Signature: <br />Date Authorized: <br />Authorized Signatures <br />RTS Signature: <br />Date: <br />Client Signature: <br />Date: <br />Client PO Number: <br />Statement of Work No. ORD- 23171- EA2EBO 6/23/09- /v -1.0 <br />Relational Technology Solutions `RTS" — Proprietary <br />11 <br />