J-5_Work_Request.pdf

FA5215‐13‐R‐7004 J‐5 Special Project Request/Approval Form

Work Request/Authorization for CLIN (X008)

SECTION A:

Ordering Activity: Contract Number:

Project POC: Phone:

Project Address/Location:

Date Ordered: Required Completion Date:

Project Control Number: Contract CLIN:

Project Description/Nomenclature:

SECTION B: (To be completed by 647 CONS/LGCZ)

This requirement is within the scope of the contract. Request you prepare a proposal and submit it to this Office by___________________________________.

Contracting Officer:______________________________ Date:________________________

SECTION C: (To be completed by the Contractor)

Point of contact:______________________ Phone:______________________________

Contractor’s Price/Cost:

REMARKS:

Project Manager:_______________________

Signature:____________________________

FA5215‐13‐R‐7004 J‐5 Special Project Request/Approval Form

Date:________________________________

SECTION D: Project Approval

Projects less than $2,500 (Services) or $3,000 (Supplies) are approved by the Functional Director (FD) /Contracting Officer Representative (COR).

Projects over $2,500 (Services) or $3,000 (Supplies) require the signatures of the FD / COR and Contracting Officer

Approved/Disapproved Approved/Disapproved

Functional Director / COR Contracting Officer

Date:________________ Date:_____________

SECTION E: Notification of Completion by Contractor

Project Completion Date:_______________________

SECTION F: Project Accepted by COR

Signature:__________________________________

Date:_______________________________