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Logistics      Other: 

*Remit To:   (Contractor name or company)
*Address:       *City:     *State:     *Zip:
*Phone:          Fax:     *Email:

*Program Name:                   *Invoice Date:

*Number of days/hrs. services were rendered: Days Hours

*Contracted Rate:

*Dates Worked:	*Invoice Total:	Additional costs to report?: No Yes
*Services Rendered: (be as specific as necessary)

	*Denotes required fields.