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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />3/2/17 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 3/14/17 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 ® George King <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <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 />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control <br />Proposal <br />® Req. to Advertise <br />Elm <br />Addendum <br />❑ Title Sheet <br />LJ Yes U No U If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />No U Yes Name of Coi <br />Spec — (G)One (1) or more 2017 or Newer One (1) ton Four Wheel <br />Drive Pick up Truck <br />2017 Solid Waste Capital Lease Principal 611-0610-415- <br />3711/Interest 611-0610-415-3712(subject to lease funding) <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment _ F-Verify Iran Ptf <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy Original <br />® ❑ Jeff Hudak & Sheila Enos, Central Services <br />® ❑ Carol Kurzhal & Mike Bronstetter, Solid Wa: <br />❑ ❑ <br />