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					                                       Attachment A

                                   State Of Nebraska

                             Moving Work Authorization

                      Request for Proposal Number 3409Z1
DATE:                                          WORK AUTHORIZATION NO.
PROJECT NAME:
OWNER PROJECT MANAGER:                                             PHONE NO.
CONTRACTOR PROJECT MANAGER:                                        PHONE NO.

                                      Description of work

This Work Authorization, with the AGREEMENT between Owner and Contractor for Moving
Services, dated between the State of Nebraska here called “Owner” and __________________
herein called “Contractor” constitutes the express authority given the Contractor by the Owner to
do moving as follows:

Minimums
2 Men and 1 van for 4 hours (within metro area)     $___________
Reimbursables:
      Overnight travel/lodging/meals                $__________
                                                    Per diem/per person




Labor
Contractor’s Designated Manager             ______hours     $______rate    $_________cost
Contractor’s Project Supervisor             ______hours     $______rate    $_________cost
Drivers/Person                              ______hours     $______rate   $_________cost
CDL Drivers/Person                          ______hours     $______rate    $_________cost
Movers/Person                               ______hours     $______rate    $_________cost

Vehicles
Tractor/Trailer (DOT group A)               ______miles $______rate $_________cost
Vehicle (continued)
Heavy Straight Truck (DOT group B)
  Over 26,001 GVWR                          ______miles $______rate $_________cost
Straight Truck under 26,001 GVWR            ______miles $______rate $_________cost
Pickup                                      ______miles $______rate $_________cost
Ancillary Costs
Commercial size tote 2.5 cube            ______quantity              $________cost
Bubble Wrap 24”                          ______quantity              $________cost
Shrink Wrap 18”                          ______quantity              $________cost
Cardboard Box 16”x21”x12” +/-            ______quantity              $________cost
Packaging Tape



TOTAL COST OF MOVE (Sum of all costs listed above) $_____________


                                       Payment

Based upon the above referenced AGREEMENT and information presented above, the moving
expense herein described is _________________________dollars ($ . )


      OWNER                                           CONTRACTOR
_________________________________         ___________________________________
By_______________________________         By_________________________________
Date_____________________________
      Date________________________________

A copy of the Work Authorization form should be attached to the invoice when submitted for
payment.

				
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