Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/14/2016 <br />Name Andrew Myer Department Fire <br />BPW Date 11/22/2016 Phone Extension 9255 <br />--- Required Prior to Submittal to Board _ <br />Legal X❑ Attorney Name M. 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 ❑ <br />L Check _the Appropriate Item Type - Required for All Submissions <br />X❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />pany or Vendor Name <br />Indiana University <br />New Vendor ❑ Yes [ <br />MBE/WBE Contractor ❑ MBE [ <br />MBE/WBE Contractor Requested ❑ No <br />Project Name N/A <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />¢. M <br />No ❑ If Yes, Approved by Purchasing <br />WBE <br />Yes Name of Company <br />The Purpose of this agreement is to allow IU Medical Sciences <br />Student to participate in an EMS Internship There will be no money <br />exchanged for this agreement. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Oniv <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy , Origi❑nal <br />❑ ❑ <br />Dispersal After Approval <br />