Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />11/14/16 <br />Jeff H <br />Department Central Services <br />BPW Date 11/22/16 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 ® <br />George King <br />Check the Appropriate <br />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 />F <br />Other: <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 />Required Information <br />Pu <br />No U Yes Name of Com <br />Spec AC — One (1) or more 2016 or Newer One Ton Two Wheel <br />Drive Dump Truck <br />2016 Water Works Capital Budget <br />622-0640-415-43-02 <br />Bid Opening Date: <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 />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Dispersal After Approval <br />Jeff Hudak & Sheila Enos <br />Bob Krol & Roxanne Lawson <br />