Attachment_5_Work_Request_Form.pdf

W900KK-17-R-0023

Attachment 5

WORK REQUEST FORM

Sequential Task Number ______ Date _________

To: PCO

Subj: REQUEST FOR AUTHORIZATION TO PROCEED WITH A WORK REQUIREMENT

Ref: (a) _________________________________________(Device/Site)

1. The undersigned Contractor requests authorization to proceed with a work requirement under

Item _______ of Contract _____________ in accordance with Section H.12 of the contract as described below:

WORK REQUIREMENT:______________________________________________

ESTIMATED MAN-HOURS:_________________________________________

ESTIMATED COST: $_____________

Detailed cost breakdown: (submit on separate sheet)

(include any necessary parts and materials)

SUBMITTED BY: (Contractor) REVIEWED BY: (COR)

(Date) (Date)

COR RECOMMENDENDATION:

[ ] Approval

[ ] Disapproval

2. [ ] Approved

[ ] Disapproved for the following reason(s)_________________________________

Contracting Officer Date