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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />11 /08/2017 <br />Chuck Bulot <br />Purchasing <br />Agreement <br />Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />❑ Other: <br />❑ Contract <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ CIO & PCA No. <br />❑ Traffic Control <br />Company or Vendor Name Auriel Informatior <br />New Vendor ❑ Yes ® No [ <br />MBEIWBE Contractor ❑ MBE ❑ WBE <br />MBEIWBE Contractor Requested ❑ No ❑ Yes <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Department Buildi <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />If Yes, Approved by Purchasing <br />Name of Company <br />IT Allocation Account <br />600-1306-415.31-76 <br />$ 24,0001yr <br />1/1/2018 — 12/31/1 S wl annual auto -renewal <br />Addendum <br />❑ Title Sheet . <br />® Required Contractor's Certification Form Attached {Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Amount of ❑ 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 />Chuck Bulot <br />Jen Hockenhull <br />