.11 Confirmation of Service Form (OS-501) SAMPLE.pdf
PDF 174 KB Posted
- Attached to
- Tree Trimming & Stump Removal Services
- Solicitation number
- 6100065337
- Issued by
- Fayette County, Pennsylvania
About this file
This is a Confirmation of Service Form (OS-501) sample document issued by the Pennsylvania Department of Transportation (PennDOT) for tree trimming and stump removal services in Fayette County. The form serves as the official documentation for vendors to confirm completion of contracted services and request payment authorization. The service encompasses tree trimming and/or stump removal work on all State Routes, PennDOT facilities, and other areas under departmental responsibility within the specified county. Waste materials including chips, mulch, leaves, and branches are to be hauled away and disposed of by the contractor, with fly chipping available upon instruction for specific projects as needed.
The Confirmation of Service Form requires vendors to document service dates, provide complete company information including SAP vendor number, reference applicable purchase order line items with corresponding quantities, unit measurements, unit prices, and item totals. The form designates specific approval authority requiring both a PennDOT Project Manager signature and an SRM/R3 Receiver signature, with the latter required within 48 hours of receipt per Management Directive 310.31, along with corresponding Goods Receipt and material document numbers. This contract opportunity is restricted to DGS-certified small businesses under the Small Business Procurement Initiative (SBPI) established by Executive Order 2011-09, and all bids must be submitted electronically through the PA Supplier Portal at www.pasupplierportal.state.pa.us.
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Text version
CONFIRMATION OF SERVICE
www.penndot.gov
Date(s) Service Rendered:________________ - _______________ Vendor Name: __________________________________________ Phone: ________________________________________________
PURCHASE ORDER #:___________________________________
SAP Vendor Number:_____________________________________ Address (1): ____________________________________________ Address (2): ____________________________________________ City: ____________________ State: _______ Zip Code: ________
(Reference line items on purchase order that match the services that were performed.)
PO Line # Description / Product ID Quantity U.O.M. Unit Price Item Total
PENNDOT USE ONLY
I certify the services represented by the confirmation of service form above were received satisfactorily. Therefore, I approve payment be made.
Project Manager Signature Date (mm/dd/yyyy)
I certify that I have entered a Goods Receipt in SAP for this service. This should occur within 48 hours of receipt (per Management Directive 310.31).
SRM/R3 Receiver Signature Date (mm/dd/yyyy) SRM Confirmation # / R3 Material Document #
Vendor Signature:_______________________________________________________________ Date:__________________________
Total of Page 1
Total of Page 2
Grand Total
Continued on page 2
$ 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
Tree Trimming and Stump Removal Service Confirmation of Service Form (0S-501) SAMPLE
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