Model_Delivery_Order.pdf

ORDER FOR SUPPLIES OR SERVICES

1. CONTRACT/PURCH ORDER/AGREEMENT NO.

FA8629-17-D-5003

2. DELIVERY ORDER/ CALL NO.

FA8629-17-F-0901

3. DATE OF ORDER/CALL

(YYYYMMMDD)

4. REQUISITION/PURCH REQUEST NO.

SEE SCHEDULE

5. PRIORITY

DO-C9

6. ISSUED BY AFLCMC/WISK CODE FA8629 7. ADMINISTERED BY (If Other than 6) CODE 8. DELIVERY FOB

USAF/AFMC/AFLCMC

AF LIFE CYCLE MANAGEMENT CENTER

1895 FIFTH STREET

WRIGHT-PATTERSON AFB OH 45433-7200

BRANDEN Q. JACKSON 937-656-8090

branden.jackson.1@us.af.mil

X DESTINATION

OTHER

(See Schedule if other)

SCD: PAS: (NONE)

9. CONTRACTOR CODE FACILITY 10. DELIVER TO FOB POINT BY (Date) 11. X IFBUSINESS IS

(YYYYMMMDD) SEE SCHEDULE

SMALL

NAME

AND

12. DISCOUNT ITEMS

SMALL DISAD-

VANTAGED

ADDRESS N

WOMEN-

OWNED

13. MAIL INVOICES TO ADDRESS IN BLOCK

SEE BLOCK 15 (PAYMENT OFFICE)

14. SHIP TO CODE 15. PAYMENT WILL BE MADE BY CODE

SEE SCHEDULE MARK ALL

PACKAGES AND

PAPERS WITH

IDENTIFICATION

NUMBERS IN

BLOCKS 1 AND 2.

EFT:T

16.

DELIVERY/

X

This delivery order/call is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract.

TYPE CALL

OF

PURCHASE

Reference your furnish the following on items specified herein.

ORDER ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE BEEN OR IS NOW MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME.

NAME OF CONTRACTOR SIGNATURE

TYPED NAME AND TITLE DATE SIGNED(YYYYMMMDD)

If this box is marked, supplier must sign Acceptance and return the following number of copies:

17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE

18. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICES 20. QUANTITY

ORDERED/

ACCEPTED*

21.

UNIT

22. UNIT PRICE 23. AMOUNT

*If quantity accepted by the Government is same as quantity ordered, indicate by X. If different, enter actual quantity accepted below quantity ordered and encircle.

24. UNITED STATES OF AMERICA

25. TOTAL

$0.00

29.

DIFFERENCES

BY:

CONTRACTING/ORDERING OFFICER

26. QUANTITY IN COLUMN 20 HAS BEEN 27. SHIP NO. 28. D.O. VOUCHER NO. 30. INITIALS

INSPECTED RECEIVED ACCEPTED, AND CONFORMS TO THE

CONTRACT EXCEPT AS NOTED

PARTIAL 32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR

_______ _________________________________________________ FINAL

DATE SIGNATURE AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32. PAYMENT 34. CHECK NUMBER

36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT. COMPLETE

_______ _________________________________________________ PARTIAL 35. BILL OF LADING

DATE SIGNATURE AND TITLE OF CERTIFYING OFFICER FINAL

37. RECEIVED

AT

38. RECEIVED BY (Print) 39. DATE RECEIVED

(YYYYMMMDD)

40. TOTAL CON-

TAINERS

41. S/R ACCOUNT NO. 42. S/R VOUCHER NO.

DD FORM 1155, JAN 1998 (EG) ConWrite Version 6.15.2 PREVIOUS EDITION MAY BE USED Created 02 Aug 2017 8:16 AM

SCHEDULE

SECTION A - CONTRACT FORM

1. PURPOSE:

The purpose of this delivery order is to procure one (1) Confined Space (CS) Kit, one (1) Structural Collapse Kit, one (1) Heavy Rapid Extrication Deployment System (REDS) Kit, and one (1) Light Rapid Extrication Deployment System (REDS) Kit. In additoin, 12 months of System Engineering/Program Management is established as a result of this Delivery Order.

SECTION B - SUPPLIES AND SERVICES

2. Section B is established as follows:

Qty Unit Price ITEM SUPPLIES OR SERVICES Purch Unit Total Item Amount

Confined Space (CS) Kit

0001 1 $0.00 Kit $0.00 Noun: CONFINED SPACE (CS) KIT

PSC: 4240

NSN: N - Not Applicable Contract type: J - FIRM FIXED PRICE Inspection: DESTINATION Acceptance: DESTINATION

FOB: DESTINATION

Descriptive Data:

The Contractor shall produce and deliver Confined Space (CS) Kits in accordance with the Statement of Objectives paragraph 2, for the Guardian Angel (GA) Technical Recovery (TR) Program.

Structural Collapse (SC) Kit

0002 1 $0.00 Kit $0.00 Noun: STRUCTURAL COLLAPSE (SC) KIT

PSC: 4240

NSN: N - Not Applicable Contract type: J - FIRM FIXED PRICE Inspection: DESTINATION Acceptance: DESTINATION

FOB: DESTINATION

Descriptive Data:

The Contractor shall produce and deliver Structural Collapse (SC) Kits in accordance with the Statement of Objectives paragraph 2, for the Guardian Angel (GA) Technical Recovery (TR) Program.

Qty Unit Price ITEM SUPPLIES OR SERVICES Purch Unit Total Item Amount

Heavy Rapid Extrication Deployment System (REDS)

0003 1 $0.00 Kit $0.00 Noun: HEAVY RAPID EXTRICATION DEPLOYMENT SYSTEM

(REDS)

PSC: 4240

NSN: N - Not Applicable Contract type: J - FIRM FIXED PRICE Inspection: DESTINATION Acceptance: DESTINATION

FOB: DESTINATION

Descriptive Data:

The Contractor shall produce and deliver Heavy Rapid Extrication Deployment System (REDS) Kits in accordance with the Statement of Objectives paragraph 2, for the Guardian Angel (GA) Technical Recovery (TR) Program.

Light Rapid Extrication Deployment System (REDS)

0004 1 $0.00 Kit $0.00 Noun: LIGHT RAPID EXTRICATION DEPLOYMENT SYSTEM

(REDS)

PSC: 4240

NSN: N - Not Applicable Contract type: J - FIRM FIXED PRICE Inspection: DESTINATION Acceptance: DESTINATION

FOB: DESTINATION

Descriptive Data:

The Contractor shall produce and deliver Light Rapid Extrication Deployment System (REDS) Kits in accordance with the Statement of Objectives paragraph 2, for the Guardian Angel (GA) Technical Recovery (TR) Program.

$0.00 Noun: SYSTEM ENGINEERING/PROGRAM MANAGEMENT

PSC: R429

Contract type: J - FIRM FIXED PRICE Start Date: 05 APR 2018 Completion Date: 04 AUG 2018 Descriptive Data:

The Contractor shall provide System Engineering and Program Management for administration and coordination of contracting actions and execution for a period of 12 months in accordance with the Statement of Objectives paragraphs 4 and 5, found in section J, Attachment 1. Pricing is in accordance with the Pricing Matrix found in Section J, Attachment 2.

SECTION F - DELIVERIES OR PERFORMANCE

SHIP MARK TRANS

ITEM SUPPLIES SCHEDULE DATA QTY TO FOR PRI DATE

0001 1 U 120 DARO

Noun: CONFINED SPACE (CS) KIT

0002 1 U 120 DARO

Noun: STRUCTURAL COLLAPSE (SC) KIT

0003 1 U 120 DARO

Noun: HEAVY RAPID EXTRICATION DEPLOYMENT

SYSTEM (REDS)

0004 1 U 120 DARO

Noun: LIGHT RAPID EXTRICATION DEPLOYMENT SYSTEM

(REDS)