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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/21/17 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date 3/28/17 <br />Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller El <br />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 />greater <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <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 />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />F1 MBE n WBE <br />❑ No ❑ Yes Name of Company <br />Spec J — Three (3) more or less 2017 or Newer Front Wheel Drive <br />Carao Vans <br />2017 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-Verify, Iran, etc. <br />Required For Chance Orders Only <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 />Dispersal After Approval <br />Jeff Hudak & Sheila Enos <br />Al Greek, Bob Krol, Roxanne Lawson <br />