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Appendix A: Change Order Form <br />Change Order # I Change Order Date <br />Change Requestor Information <br />Company Name <br />City of South Bend <br />Name & Title <br />Phone <br />Email <br />Description of Requested Change <br />NOTE: Change Orders must be reviewed and authorized by CNA for acceptance of the requested cliange. Unanges to the scope of <br />an implementation may require additional software components and/or Professional Services to make the requested change <br />operational - where this may result in additional costs. <br />Additional software components required: YesEl No Additional Professional Services required: Yes 11 No ID <br />Change Authorization Approval <br />Change authorized for City of South Bend by: <br />Print Name Print Title <br />Signature Date <br />Change authorized for Canon Solutions America, Inc. by: <br />Print Name Print Title <br />Signature Date <br />This document is the property of and is proprietary to Canon Solutions America. It is not to be disclosed in Page 23 <br />whale or in part without prior written consent of Canon Solutions America, and shall not be duplicated or used in <br />CANON S(MUMNSAMEPICA whole or in part, for any purpose other than to evaluate Canon Solutions America's proposal, and shall be returned SER-035 <br />upon request. December 30, 2016 <br />