Laserfiche WebLink
Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />6/30/17 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 7/11/17 Phone Extension 574-235-9316 <br />❑ <br />Agreement <br />'❑ <br />Contract U Proposal L Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />I -I <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 />j__.,J Yes j___.J No Lj If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec V - Four (4) more or less 2017 or Newer Mid -Size Four Door <br />Hybrid Sedan Automobiles <br />2017 Waste Water Capital Budget 642-0630-415-43-02 <br />2017 Fire Department Capital Budget 287-0902-422-43-02 <br />Bid Opening Date: <br />F ] 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 />Copy <br />Original <br />® <br />❑ <br />Dispersal After Approval <br />Jeff Hudak & Sheila Enos <br />-Al Greek, Ken Smith, Carol Kurzhal <br />Todd Skwarcan <br />