A.02.12 Attachment K - Sample SO Submission Form_Amend 0002.pdf
PDF 127 KB Posted
- Attached to
- Recurring Maintenance and Minor Repair Services Naval Station Rota and Moron Air Base, Spain
- Solicitation number
- W912GB23R0036
- Issued by
-
Department of the Army European Command
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Text version
CONTRACTOR:
CUSTOMER ORGANIZATION:
DOD SITE CODE:
FACILITY NAME/NUMBER: SO REQUEST NO:
SERVICE ORDER DATE:
Action to be Taken:
One of these boxes must be checked: ROUTINE EMERGENCY CENAU Safety Initial
Check if applicable:
Labor Classification Reg Labor Hours
Reg Labor Rate
Reg Labor Amount OT Hours Contr O/T Rate OT Amount
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 10.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Qty Unit Unit Price Amount $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Amount $0.00 $0.00 $0.00
$0.00
$0.00
Freight/ShippingSUB Notes:
CORRECTIVE MAINTENANCE SERVICE ORDER FORM
PART I - SERVICE ORDER INFORMATION
LABOR UTILIZED
MATERIALS/SUPPLIES/EQUIPMENT
Total Regular Labor
TOTAL LABOR COST
Safety Verification to be completed by Contractor
One of these boxes must be checked:
Contractor confirms there is an AHA associated with the work being performed in this SO included in the Accident Prevention Plan (APP) Contractor acknowledges there is NOT an AHA associated with the work being performed in this SO included in the APP. AHA is attached for review with the SO.
Contractor acknowledges there is an activity associtated with the SO that requires an additional plan or program that will be included in an APP addendum.
SO Descripton (include LOCATION - attach additional sheets as required):
PART II - COST SUMMARY
Total OT Labor Profit On Labor: 0%
Tax: 0% MSE Charge Rate: 0%
Profit On MSE: 0%
Description
SUBCONTRACTOR COSTS
NOTE: Profit shall not be applied to GSA/JCI Catalog Materials.
Description
Freight/Shipping
Fully Burdened MSE
Safety Officer will inspect before, during and after work. Quality Control Officer will inspect during testing.
MSE Notes:
W912GBXXCXXXX
CONTRACT Year:
SERVICE ORDER NAME:
Labor Notes:
CONTRACT NO.:
CLIN TO BE CHARGED:
SUB Charge Rate: 0%
TOTAL SUB COST
Subtotal MSE
TOTAL MSE COST
CONTRACTOR:
CUSTOMER ORGANIZATION:
DOD SITE CODE:
FACILITY NAME/NUMBER: SO REQUEST NO:
SERVICE ORDER DATE:
Action to be Taken:
One of these boxes must be checked: ROUTINE EMERGENCY
CORRECTIVE MAINTENANCE SERVICE ORDER FORM
PART I - SERVICE ORDER INFORMATION
SO Descripton (include LOCATION - attach additional sheets as required):
W912GBXXCXXXX
CONTRACT Year:
SERVICE ORDER NAME:
CONTRACT NO.:
CLIN TO BE CHARGED:
Amount $0.00 $0.00 $0.00
ODC Notes: $0.00
$0.00
$0.00
Amount $0.00 $0.00
Travel Notes: $0.00
$0.00
CENAU COR: May approve SOs up to $10,000 or as otherwise authorized by the Contracting Officer.
TRAVEL
G&A: 0%
OTHER DIRECT COSTS
TOTAL ODC COST
E-SIGNED & DATED:
CONRACTOR: Receipt & Acceptance Acknowledged.
Description
PART IV - CERTIFICATION OF SERVICES
CONTRACTING OFFICER: Service Orders over $10,000 or as otherwise specified by Contracting Officer.
QUAILITY ASSURANCE EVALUATOR:
E-SIGNED & DATED:
E-SIGNED & DATED:
This is a cost reimbursable service order and the initial prices submitted reflect the Contractor's best estimate to complete the work necessary to satisfy the requriement. This SO is considered technically acceptable and within scope.
DATE/TIME WORK COMPLETED
TOTAL TRAVEL COST
E-SIGNED & DATED:
$0.00TOTAL SO COSTS TO BE INVOICED
PART III - AUTHORIZATION
E-SIGNED & DATED:
CUSTOMER: SO is accepted and requests NTP from USACE.
I certify that the services under the above Service Order have been satisfactorily completed.
Profit on Outside Vendor: 0%
Description
Equipment room flooded. Need to remove excess water for safety purposes.
G&A: 0%
Service Order
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