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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />4/3/17 <br />Jeff Hudak <br />Department Central Services <br />H <br />Agreement <br />U Contract L Proposal LJ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEIWBE 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 />U Yes LJ No L If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec L — One (1) or more 2017 or Newer 3% Ton Extended Cab <br />Four Wheel Drive Pick Up Truck <br />2017 Venues, Arts, & Parks Capital Lease 201-1101-452-37-11 & <br />Interest 201-1101-452-37-12 (subject to lease funding) <br />$ <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment, E-Verifv. Iran. etc. <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 <br />® ❑ Cecil Eastman & Paul Moreland <br />