Work Request Template
NAVFAC 9-11014/20 REV. 2-68) S/N 0105-LF-002-7510 Instructions in NAVFAC MO-321)
Supersedes NAVDOCKS 2351
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PART I - REQUEST (Filled out by Requestor)
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1. FROM
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2. REQUEST NO.
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3. TO
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4. DATE OF REQUEST
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5. REQUEST FOR
☐ COST ESTIMATE ☐ PERFORMANCE OF WORK
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5a. REQUEST WORK START
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6. FOR FURTHER INFORMATION CALL
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7. SKETCH/PLAN ATTACHED
☐ YES ☐ NO
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8. DESCRIPTION OF WORK AND JUSTIFICATION (Including location, type, size, quantity, etc.)
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9. FUNDS CHARGEABLE
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10. SIGNATURE (Requesting Official)
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PART II - COST ESTIMATE
(Filled out by Maintenance Control Division if estimate requested)
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11. TO:
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12. ESTIMATE NO.
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13. COST ESTIMATE
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14. SKETCH/PLAN ATTACHED
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☐ YES ☐ NO
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a. Labor
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15.
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b. Material
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☐ APPROVED: PROGRAMMING TO START IN .
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| c. Overhead and/or Surcharge |
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☐ APPROVED: BASED ON PRESENT WORKLOAD, THIS JOB CAN BE
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| d. Equipment Rental/ Usage |
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PROGRAMMED TO START IN , IF
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e. Contingency
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AUTHORIZED BY 25TH OF AND FUNDS ARE MADE AVAILABLE.
☐ DISAPPROVED. (See Reverse Side)
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f. TOTAL
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16. SIGNATURE
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17. DATE
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PART III - ACTION (Filled out by Requestor)
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18. TO:
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19. AUTHORIZATION TO PROCEED IS ATTACHED (Check one if other than PW funds are involved)
☐ NAVCOMPT 140 ☐ OTHER
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20. WORK REQUESTED
HAS BEEN HAS BEEN WILL BE PERFORMED
☐ CANCELLED ☐ DEFERRED ☐ BY OTHERS
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21. SIGNATURE
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22. DATE
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