SJA800-16-Q-0024_-_Attachment_1_-_Sample_Task_Order_Form.pdf

Request for Quotations (RFQ) No. SJA800-16-Q-0024

Attachment 1

Attachment 1 - Sample Task Order Form

ORDER FOR SUPPLIES OR SERVICES

PAGE OF PAGES

IMPORTANT: Mark all packages and papers with contract and/or order numbers. 1

1. DATE OF ORDER 2. CONTRACT NO. (If any) 6. SHIP TO:

(to be determined) (to be determined) a. NAME OF CONSIGNEE

3. ORDER NO. 4. REQUISITION/REFERENCE NO. U.S. Embassy

b. STREET ADDRESS

5. ISSUING OFFICE (Address correspondence to) 1-10-5 Akasaka

U.S. Embassy c. CITY d. STATE e. ZIP CODE

Minato-ku, Tokyo

107-0052

7. TO: f. SHIP VIA

a. NAME OF CONTRACTOR

(to be determined) 8. TYPE OF ORDER

b. COMPANY NAME [ ] a. PURCHASE [ ] b. DELIVERY -- Except REF YOUR: ________________ for billing instructions on the reverse, this

c. STREET ADDRESS Please furnish the following on the terms delivery order is subject to instructions

And conditions specified on both sides of contained on this side only of this form

d. CITY e. STATE f. ZIP CODE This order and on the attached sheet, if and is issued subject to the terms and

Any, including delivery as indicated. conditions of the above-numbered contract.

9. ACCOUNTING AND APPROPRIATION DATA

Funds will be obligated at the time an order is placed.

10. REQUISITIONING OFFICE

Facility Management Office

11. BUSINESS CLASSIFICATION (Check appropriate box(es))

a. SMALL b. OTHER THAN SMALL c. DISADVANTAGED d. WOMEN-OWNED

12. F.O.B. POINT

Destination

14. GOVERNMENT B/L NO. 15. DELIVER TO F.O.B. POINT ON

OR BEFORE (Date)

16. DISCOUNT TERMS

13. PLACE OF n/a Indefinite Net 30

a. INSPECTION

See Block 6.

b. ACCEPTANCE

See Block 6.

17. SCHEDULE (See reverse for Rejections)

ITEM NO.

(a)

SUPPLIES OR SERVICES

(b)

QUANTITY

ORDERED

(c)

UNIT

(d)

UNIT

PRICE

(e)

AMOUNT

(f)

QUANTITY

ACCEPTED

(g)

Task Order

Pursuant to the authority of FAR 52.216-18 Ordering, the Contractor shall perform painting services for the following location(s) in accordance with terms and conditions of the contract, effective the start of performance through the completion and final acceptance of the work:

(to be determined)

18. SHIPPING POINT

19. GROSS SHIPPING WEIGHT

20. INVOICE NO.

17(h) TOT.

SEE 21. MAIL INVOICE TO: (Cont.

BILLING a. NAME pages) INSTRUCTIONS Financial Management Officer

ON b. STREET ADDRESS (or P.O. Box) REVERSE 1-10-5 Akasaka 17(i)

c. CITY d. STATE e. ZIP CODE GRAND Minato-ku, Tokyo

107-8420 TOTAL

22. UNITED STATES OF

AMERICA BY (Signature)

23. NAME

(Name of Contracting Officer)

TITLE: CONTRACTING/ORDERING OFFICER

OPTIONAL FORM 347