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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />9/29/17 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 10/10/17 Phone Extension 574-235-9316 <br />❑ Agreement <br />Contract L Proposal L Addendum <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 />f-1 <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/VVBE 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 L- J <br />El <br />❑ Yes ❑ No ❑ if Yes, Approved b Purchasin <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec AC — One (1) or more 2018 or Newer % Ton Extended Cab <br />Four Wheel Drive Pick Ur) Truck <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ Jeff Hudak & Sheila Enos <br />® <br />❑ Darric Cole & Roxanne Lawson <br />❑ <br />❑ <br />