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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />w <br />8/23/16 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 9/13/16 Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />Check the Appropriate Item Tvpe — Required for All Submissions <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control <br />No I I Yes Name of <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />u <br />❑ Title Sheet <br />Extension Award (2016 Spec W) — One (1) 2016 or Newer Full Size <br />Cargo Van <br />$36, <br />Bid Opening Date: 5/10/16 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ Jeff Hudak & Sheila Enos <br />® <br />❑ Al Greek & Carol Kurzhal & Ken Smith <br />❑ <br />❑ <br />