Attachment_11_-_VBM_Form_2_fillable.docx

VBM Form-2

Instructions: Print, type or use the drop down menus (where applicable) to answer the questions.

Government Request for Barrier Repair Circuit Number:

USMS District Number:

USMS Site Code Number:

City:

State:

Address:

Street:

Zip Code:

Barrier Manufacturer:

Barrier Type:

Crash Rated:

Crash Rating:

Provide a description of the problem:

Contractor(s) Proposal Number of technicians required:

Number of technician labor hours:

Lead labor cost rates:

Number of technicians required:

Number of technician labor hours:

Labor cost rates:

Number of technicians required:

Number of technician labor hours:

Labor cost rates:

Part/material required:

Quantity:

Part Description:

Cost:

Part/material required:

Quantity:

Part Description:

Cost:

Part/material required:

Quantity:

Part Description:

Cost:

Part/material required:

Quantity:

Part Description:

Cost:

Other Costs ODC/Cost:

ODC/Cost:

ODC/Cost:

ODC/Cost:

Rental Equipment/Cost:

Travel:

Sub-Contractor/Cost:

Contractor Preparer’s Printed Name:

Signature:

Date:

Comments (optional):

COR Approval COR’s Printed Name:

Signature:

Date:

Comments (optional):