Board Of Aldermen - Agenda - 10/6/2020 - P86

Attachment 12 — Customer Change Order Authorizations Form

CUSTOMER CHANGE ORDER AUTHORIZATION FORM

DESCRIPTION OF CHANGE:

Sample Language - EET was given Notice to Proceed (NTP) on xx/xx’‘xx and proceeded with the
final design and procurement of ...... This Change Order reflects the .....

See Attachment A — Additional Supportmg Documents;

a

Reference Documents — Email from / to Subject, Date

CONTRACT VALUE:

ount

£ o
- o

The Change Order becomes part of and is in conformance with the existing Agreement. All rere ond conditions of

the agreement apply.

Customer Authorized
Signature:

Name:

Title:

Date:

EE] Authorized Signature
Signature:
Name:
Title:
Date: