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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />10/17/16 <br />Department Central Services <br />BPW Date 10/25/16 Phone Extension 574-235-9316 <br />Jeff Hudak <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ❑ <br />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 ® <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />® <br />Other: Rejection: User <br />department <br />needed a <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEM/BE 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 />Kequirea mrorma <br />Yes No ❑ If <br />MBE ❑ WBE <br />LJ No LJ Yes Name of Company <br />Spec M — Two (2) more or less 2016 or Newer 3/4 Ton Two Wheel <br />Drive Pick Up Trucks <br />Bid Opening Date: 2/23/16 <br />❑ Required contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />Dispersal After Approval <br />Jeff Hudak & Sheila Enos <br />Roxanne Lawson & Bob Krol <br />