CUSTOM PROGRAM SIGNATURE FORM - VOLUME LICENSINGIi Microsoft
Custom Program Signature Form
MBNMBSA number
Agreement number
N/A
01E73902
Volume Licensing
000-shaylari-0057
Note: Enter the applicable active numbers associated with the documents below. Microsoft requires
the associated active number be indicated here, or listed below as new.
For the purposes of this form, *Customer* can mean the signing entity, EnroNed Affiliate,
Government Partner, Institution, or other party entering into a volume licensing program agreement.
This signature form and all contract documents identified in the table below are entered into between
the Customer and the Microsoft Affiliate signing, as of the effective date identified below.
Contract Document
Enter • rise Enrollment Indirect
Product Selection Form
Ente • rise Amendment
Number or Code
X20 -10634
0611366.002 PSF
M97 N
By signing below, Customer and the Microsoft Affiliate agree that both parties (1) have received, read
and understand the above contract documents, including any websites or documents incorporated by
reference and any amendments and (2) agree to be bound by the terms of all such documents.
Customer
Name of Entity (must be legal entity name)* City of Clearwater
Signature* Cj GO rN.e. /\Cf c\k-ltoS
Printed First and Last Name' George N. Cretekos
Printed Title Mayor
Signature Date*
Tax ID
• indicates required field
ATTEST:
APPROVE ' AS TO Fiii; M:
Signatu -•
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Signatu ; t
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Printed Name•
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Printed Name*
Rosemarie Call
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Printed Title"
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Printed Titled*
City Clerk
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As City Attorney
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Page 1 of 2
Signature' /� f�
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Printed Name`
Printed Title'
City Manager
Signature
Printed First and Last Name
Printed Title
Signature Date
(date Microsoft Affiliate countersigns)
Agreement Effective Date
(may be different than Microsoft's signature date)
r1ir_ra5oft Affifial",
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croso rporati • n
JU 0 7 2017
Shirley Snyder
lcrosoft Corporation
If Customer requires physical media, additional contacts, or Is reporting multiple previous Enrollments,
include the appropriate form(s) with this signature form.
After this signature form is signed by the Customer, send it and the Contract Documents to Customer's
channel partner or Microsoft account manager, who must submit them to the following address. When
the signature form is fully executed by Microsoft, Customer will receive a confirmation copy.
Microsoft Corporation
Dept. 551, Volume Ucensing
6100 Nell Road, Suite 210
Reno, Nevada 89511 -1137
USA
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