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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />2016-12-09 <br />Rene Casiano <br />Department Office of Innovation <br />BPW Date 2016-12-22 Phone Extension 5897 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />® Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />F1 Other: <br />Company or Vendor Name <br />New Vendor <br />Yes N No ❑ If Yes, Approved by Purchasing <br />MBEANBE Contractor ❑ MBE ❑ WBE <br />MBEANBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name Fusion API <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />IT Professional Services <br />404-0672-415-31-06 <br />$ 9,680 <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Fusion <br />Required Contractor's Certification Form Attached (Non- <br />usion, Non -Discrimination. Non -Debarment. E-Verifv. Iran. et( <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />