Engineering Change Order Form
Requested Date
-
Month
-
Day
Year
Date
Project Title/Name
Contract No.
Project Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project Status
In progress
On hold
Client's Name
First Name
Last Name
Assigned Engineer
First Name
Last Name
Contractor/Service Provider Company
Please fill up the table below:
Description of Change
Reason
Priority
Change Type
1
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
2
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
3
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
4
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
5
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
6
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
7
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
8
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
9
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
10
Client Request
Performance/Reliability
Safety
Cost Reduction
Error
Part replacement
Enhancement/Upgrade
Urgent
High
Low
Permanent
Temporary
Summary of Changes
Allocation/Distribution
Labor/Materials/Other
Quantity/# of Hours
Amount/Rate ($)
Cost ($)
1
2
3
4
5
6
7
8
9
10
Total Amount ($)
Original Budget ($)
Revised Budget ($)
Signatures
Signature of Engineer who recommend the changes
Date Signed
-
Month
-
Day
Year
Date
Signature of the Owner who approved the changes
Date
-
Month
-
Day
Year
Date
Name of Representative from the Service Provider
First Name
Last Name
Signature of the Contractor/Service Provider Representative
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: