Dd Form 428 - Communication Service Authorization

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COMMUNICATION SERVICE AUTHORIZATION
3. CIRCUIT OR BILL NUMBER
1. AUTHORIZATION
2. AUTHORIZATION
a. NUMBER
b. DATE
a. NUMBER
b. DATE
(YYYYMMDD)
(YYYYMMDD)
4. FROM
5. SUBMIT BILLS FOR CERTIFICATION TO
(Include ZIP Code)
(Include ZIP Code)
7. TELEPHONE NUMBER TO CONTACT FOR DETAILS
6. TO
(Communications Company)
(Include Area Code)
a. COMPANY NAME
8. AUTHORIZATION. In accordance with provisions of the contract
indicated above of which this authorization forms a part, authority
b. ADDRESS
is hereby given to Communications Company indicated in Item 6 to
(1) STREET
establish or perform services for official use as prescribed below at:
(2) CITY
(3) STATE
(4) ZIP CODE
9. SERVICE(S)
d. RATE PER MONTH
NON-RECURRING
DESCRIPTION
NUMBER
CHARGE
PER UNIT
TOTAL
a.
b.
c.
(1)
(2)
11. DISTRIBUTION
10. DISBURSING OFFICER MAKING PAYMENT
a. NAME (Last, First, Middle Initial)
b. GRADE
12. AUTHORIZING OFFICIAL
a. SIGNATURE
b. TITLE
c. GRADE
13. ACCEPTANCE
a. NAME OF CONTRACTING FIRM
b. SIGNATURE OF CONTRACTOR'S REPRESENTATIVE
c. DATE SIGNED
(YYYYMMDD)
DD FORM 428, MAY 1999
PREVIOUS EDITION IS OBSOLETE.
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