CITY OF PHILADELPHIA
PROJECT AND SERVICE REQUEST
CAPITAL PROGRAM OFFICE
TO BE COMPLETED BY REQUESTING AGENCY:
1401-1499 J.F.K. BOULEVARD
PHILA., PA 19102
REQUESTING AGENCY
AGENCY CONTACT
PHONE NO.
DATE:
1. SCOPE OF SERVICES REQUIRED
2. LOCATION(S) OF PROJECT(S) - (INCLUDE ADDRESS)
4. SOURCES OF FUNDS
AMOUNT AVAILABLE
ACCOUNT CODE
Operating Budget - Requesting Agency
DESIRED COMPLETION DATE
Capital Budget - Line & SubProject _______________________
Requirements Contract
Unknown
Other
AUTHORIZED SIGNATURE
TITLE
DATE
TO BE COMPLETED BY CAPITAL PROGRAM OFFICE:
RECEIVED BY
DATE
FUNDING & BUDGET INFORMATION VERIFICATION
:
CIRCLE PROFESSIONAL SERVICES REQUIRED
ARCHITECTURAL
SURVEY & PLANNING
ENGINEERING
OTHER ____________________________________________
TEAM
PROJECT COORDINATOR ASSIGNED
PRIORITY
PHONE
PROJECT NUMBER
ESTIMATED COST
COST PER SQUARE FOOT IF APPLICABLE:
DISPOSITION:
PROJECT DIRECTOR SIGNATURE
DATE
PROJECT START DATE
3-7-97