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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />10/18/17 <br />Ken Glowacki <br />Purchasing <br />Department Police <br />ICJ Agreement <br />H Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />Other: <br />Company or Vendor Name <br />Shein Realty <br />New Vendor <br />❑ Yes® No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBENVBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />ATF Project Disarm Taskforce <br />Project Number <br />Funding Source <br />Continuing Education Fund -amount is 100% reimbursed by ATF <br />Account No. <br />220-0801-421.39-89 <br />Amount <br />$10,480.00 <br />Terms of Contract <br />One year renewal <br />Purpose/Description <br />with ATF for Prolect reimbursed by <br />� <br />.orm-lease <br />� Required Contractor's Certifi'oins <br />cation <br />tin 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 />❑ <br />❑ <br />Ken Glowacki <br />�a <br />d/Q <br />Dispersal After Approval <br />