Project No.:

File No.:

Contract No.:

Customer Department:

Design Change Serial No.:

Contractor:

Permanent Change

Deviation

1. Description of change and Reasons:

Total Estimated Cost:

Contractor's Signature: _______________________________________

Contractor's Signature Date (YYYY-MM-DD):

2. Customer Department:

Approved: _______________________________________

Customer Department Date (YYYY-MM-DD):

3. Total Firm Price of Change:

Procurement Officer: _______________________________________

Total Firm Price of Change Date (YYYY-MM-DD):

4. Change, if any, on Delivery Schedule:

5. Aggregate Value of Design Changes:

1. Additional Information:

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