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EXHIBIT D, AUTHORIZED DEALER FORM <br />Manufacturer Name: <br />(Check one) <br />❑ The Dealer listed below is authorized to provide Products and Services in accordance with the <br />NASPO ValuePoint Copiers and Managed Print Services Master Agreement. <br />❑ The Dealer listed below will no longer provide Products and Services under the NASPO ValuePoint <br />Copiers and Managed Print Services Master Agreement for the following reason: <br />State(s) Serviced by <br />Dealer: <br />Dealer Name: <br />Address: <br />Phone (include Toll -Free, if <br />available): <br />Contact Person(s): <br />Email Address: <br />FEIN: <br />Signed: <br />(Contractor Representative) <br />Date: <br />Signed: Date: <br />(Authorized Dealer Representative) <br />(Print First and Last Name of Authorized Dealer Representative) <br />Page 68 <br />Copiers and Managed Print Services - RFP-NP-18-001 NASPO ValuePoint Master Agreement Teams and Condidao, CMS # 140603 <br />25B-79 <br />