Contract Name

Reference Number

Confirmation Notice Number

For implementing Authority Change Notice

Issued to

(Individuals Name)

Acting for Service Provider

(Service Providers Name)

Name of Confirmation Notice

(short name for ease of reference)

Authority Change Notice

(Short name for ease of reference)

Detail of Authority Change Notice and any subsequent revisions

This Confirmation Notice Form instructs the provision of the Medium Value Change set out in the Appendix in accordance with the Contract and the Change Protocol

Details of Service Provider Response Number to above Authority Change Notice

Date of agreement to Service Provider Response

Date  /  /200

Issued by

(Signature)

Date  /  /200

Name & Position of above

The above date is deemed to be the date of issue

Received by

(Signature)

Date  /  /200

Name & Position of above