Request For Change Order Form
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1Commonwealth of Pennsylvania
Project No.____________________Phase_____Part______
Change
Department of General Services
Request
Contract No.______________________________________
Order No._________
Construction Change Order Section
for
Project Title______________________________________
For CO Section use only
18th & Herr Streets
Change
Location__________________________________________
Page 1 of____
Harrisburg, Pennsylvania 17125
Order
SECTION 1- TO BE COMPLETED BY ORIGINATOR (PROFESSIONAL, CONTRACTOR, DGS)
DATE:
The Originator of this Change Order Request is:
Professional
Professional for Using Agency
Contractor
DGS
DGS Inspector Supervisor/Manager
has confirmed that this C/O will be routed:
REGULAR
EXPEDITED
and that a FAX route is not required.
Description of Work:
(For additional space to provide description, use Request for Change Order Continuation Sheet)
Name, Signature and address of Originator:
Note: The Professional as Originator shall complete Sections 1 & 2.
Name:
All other Originators shall complete Section 1 ONLY and
Signature:
forward to the Professional for further processing.
Company:
Address:
DATE RECEIVED FROM ORIGINATOR:
SECTION 2- TO BE COMPLETED BY PROFESSIONAL
If you do not concur with the need, benefit or legitimacy of this Change Order, explain why:
Provide revised description if different from SECTION 1 above (this will be used as a preliminary scope):
(For additional space to provide description, use Request for Change Order Continuation Sheet)
This Change Order is a direct result of (choose one only)
Request of the Using Agency
Post Design Code Revision
Professional’s Error or Omission
Unforeseen Condition
Other
Explain Cause Choice:
Professional Guesstimate for this Change Order:
$
Debit
Credit
No Cost
DATE:
Note: Guesstimate not required for C/O’s routed EXPEDITED
Forward EXPEDITED C/O Request TO: FROM: Company Name:
Forward REGULAR C/O Request TO:
Signature:
Director, Bureau of Construction
DGS Regional Inspector Supervisor/Manager
Address:
Department of General Services
referenced in SECTION 1 of this Request.
Phone No.:
Room 300, Arsenal Building
Fax No.:
18th & Herr Streets, Harrisburg, PA 17125
SECTION 3 -TO BE COMPLETED BY BUREAU OF CONSTRUCTION CHANGE ORDER SECTION PERSONNEL ONLY
____________
_________
_____________
Date Received:
Computer Assigned Change Order No.
Funds Available Date:
This serves as authorization for the Professional to begin preparing the subject scope-of-work, and all necessary design
change documents. The Professional shall submit Form GSC-1 to the Contractor to initiate the Change Order process. Both the
Professional and Contractor shall complete Form GSC-1 in accordance with this Administrative Procedure.
____________________________________
Change Order Section Authorization
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