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[Project Name] Change Request

Client Project Name Job Number Change name Date Submitted Requested by Submitted by [short description] [mm/dd/yy]

Change Request Number

[nnnn]

Detailed Description of Change [description]

Impact Analysis Schedule Cost Related affects to other projects or parts of this project Decision and Rationale [description]

Approval: Approved by: Approval date:

[signature] [name] [mm/dd/yy]

Confidential-For internal Use Only

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