Change Order Request Form - Draft Page 2

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CHANGE ORDER REQUEST FORM
CONTRACT NO. ___________________
UPON WRITTEN REQUEST FROM THE ENGINEER, PROVIDE ADDITIONAL DETAIL
DATE RECEIVED REQUEST FOR
SUBMITTAL DATE OF
ADDITIONAL DETAIL
ADDITIONAL DETAIL
DETAILED DESCRIPTION / JUSTIFICATION:
(Include location(s), actions of contractor, owner, and other stakeholders, key events and related cause(s), discoveries,
discussions, meetings, and effect on the contract if no action is taken. Also include references to key documents attached
or available to support this change order request.)
PROPOSED SOLUTION – ADDITIONAL DETAILS:
(Include proposed scope of work, means & methods, materials, equipment, utility relocation required, subcontracted
scope and the effect on the contract schedule. Also include references to attached documents including, but not limited
to, sketches, calculations, photos, material information, and submittals and meeting minutes.)
SIGNATURES
Contractor:
Name: (print) _____________________________________________________
(signature) _______________________________________________________ Date: ___________________________
Project Engineer/Supervisor:
(signature is to acknowledge receipt of the document and does not signify agreement of the change order)
Name: (print) _____________________________________________________
(signature) _______________________________________________________ Date: __________________________
NOTE: The Contractor and PE/S should retain a signed copy of this document for record.
Page 2

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