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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />4/18/17 <br />Jeff Hudak <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE 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 />Department Central Services <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc <br />Amount of ❑ Increase $ <br />❑ <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 />Cecil Eastman, Paul Moreland, Aaron Perri <br />