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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2-7-2017 Department Fire <br />BPW Date 2-14-2017 Phone 9255 <br />Name Todd Skwarcan <br />o Legal ® Attorney Name Michael Schmidt <br />o Controller review is required for all Contracts $5,000.00 or more <br />o o Controller ❑ and greater than one year in length per the City Purchasing <br />o m Policy <br />co Purchasing ❑ <br />Check the Appropriate Item Tvoe — Reauired for All Submissions <br />® Agreement <br />❑ Contract I <br />❑ Proposal <br />❑ Addendum <br />❑ Claim <br />❑ Bid Opening <br />❑ Bid Award I <br />❑ Reg. to Advertise <br />❑ Title Sheet <br />❑ Quote Opening <br />Quote Award <br />❑ Chg Order No. <br />❑ C/O & PCA No. <br />❑PCA <br />❑ Ease./Encroach. <br />❑ Traffic Control <br />❑ Resolution <br />❑ Other: <br />mtormation <br />Company or Vendor Name <br />Memorial Hospital <br />New Vendor <br />❑ Yes <br />LA <br />No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />5 year <br />Purpose/Description <br />Ambulance staffing agreement <br />Amount of <br />Increase <br />Decrease <br />For Change Orders O <br />Total Percent of Change: % <br />PO No. <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />