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Service Order Form
| SERVICE ORDER FORM | |
| PART I - SERVICE ORDER INFORMATION | |
| CONTRACTOR: | CONTRACT NUMBER: |
| SITE/BASE NAME : | TASK ORDER NUMBER: |
| FACILITY NAME : | CLIN NUMBER: |
| Building #, Room #: | SERVICE CALL DATE:(DDMMMYYYY) |
| SO ORDER NO: | SERVICE TICKET NUMBER: |
| SERVICE ORDER DATE: (DDMMMYYYY) | TYPE: Routine, Emergency, PMI. |
| INITIATOR: | SCHEDULE OF COMPLETION (DDMMYYYY) |
| SOW (attach additional sheets as required): | |
| Safety Verification to be completed by Contractor | | CEHNC Safety Initial |
| One of these boxes must be checked: | Contractor confirms there is an AHA associated with the work being performed in this SO included in the Accident Prevention Plan (APP) | NA |
| Contractor acknowledges there is NOT an AHA associated with the work being performed in this SO included in the APP. AHA is attached for review with the SO. | |
| Check if applicable: | Contractor acknowledges there is an activity associated with the SO that requires an additional plan or program that will be included in an APP addendum. | |
| PART II - COST SUMMARY | | | | | | |
| LABOR UTILIZED | | | | | | |
| Labor Classification | Reg Labor Hours | Reg Labor Rate | Reg Labor Amount | OT Hours | Contr O/T Rate | OT Amount |
| Contractor Technician | | | $0.00 | | | $0.00 |
| Contractor Technician (Senior) | | | $0.00 | | | $0.00 |
| Maintenance Manager | | | $0.00 | | | $0.00 |
| | | $0.00 | | | $0.00 |
| Travel to/from Site | | | $0.00 | | TOTAL OT LABOR | $0.00 |
| TOTAL REGULAR LABOR | | | $0.00 | | TOTAL LABOR | $0.00 |
| PARTS/MATERIALS/SUPPLIES | | | | | | |
| Description | Qty | Unit | Unit Euro Price | Exchange Rate | Unit US Price | Amount |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| | | | | $0.00 | $0.00 |
| SUBCONTRACTS | | | Sub Total Parts/Materials/Supplies | | Rate | $0.00 |
| | $0.00 | Material Shipping Cost | | | $0.00 |
| | $0.00 | Tax (%) | | | $0.00 |
| | $0.00 | Material Handling (%) | | | $0.00 |
| | $0.00 | Total Mat/Sup Cost | | | $0.00 |
| | $0.00 | Total Labor | | | $0.00 |
| Subtotal Subcontracts | | $0.00 | Total Mat/Sup/Labor Cost | | | $0.00 |
| Subcontractor Handling Charge (Enter Rate) | 0.00% | $0.00 | Profit (%) | | | $0.00 |
| | | Total Subcontractor Cost | | | $0.00 |
| Total Subcontractor Price | | $0.00 | Total Service Order Cost | | | $0.00 |
| TOTAL TO BE INVOICED | $0.00 |
| PART III - AUTHORIZATION | |
| On Site Representative (OSR) Concurrence: | DATE |
| OSR Printed Name: | |
Engineering Concurrence: DATE
Service Order Authorized
| ORDERING OFFICER: | DATE |
| FUNDING MOD/SUB-CLIN: | |
| SIGNED: | |
| CONTRACTING OFFICER | DATE |
| PART IV - CERTIFICATION OF SERVICES | |
| I certify that the services under the above Service Order have been satisfactorily completed. | |
| CONTRACTOR SIGNATURE | DATE |
| CONTRACTOR PRINTED NAME | |
| OSR QUALITY ASSURANCE EVALUATOR | DATE |
| OSR PRINTED NAME | |
