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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />02/14/2017 <br />Department Sustainability <br />BPW Date 02/14/2017 Phone Extension <br />Required Prior to Submittal to Board <br />Legal Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Therese Dorau <br />Purchasing ❑ <br />Check the A <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Chg Order No. <br />Ease./Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Addendum <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control ❑ Resolution <br />❑ Claim <br />Required Information <br />El Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE ❑ No <br />City -Wide Curbside Recycling Services <br />Solid Waste Recycling Services <br />For Chanqe Orders O <br />Amount of <br />Increase <br />Dec <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />