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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 5/31/17 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date 6/13/17 <br />Phone Extension 574-235-9316 <br />Re' uired'Prior:to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® <br />George King <br />C heck` the Appropriate: <br />l#em T pe Required far All Submissions <br />❑ <br />Agreement <br />Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />® <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEMIBE Contractor <br />MBEIWBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Hull Lift Truck <br />F1 Yes __ No ❑ If Yes, Approved by Purchasinq <br />MBE U WBE <br />_❑ No ❑ Yes Name of Company <br />Spec N -- One (1) or more 2017 or Newer LP Powered Lift Truck <br />2017 Waste Water Capital Budget <br />642-0630-415-43-02 <br />$ 29,459.00 <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 />® ❑ Al Greek, Ken Smith, Carol Kurzhal <br />