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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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