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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />12/5/17 <br />Todd Skwarcan <br />Department Fire <br />U Agreement <br />H Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />® <br />Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />�I Other: <br />Company or Vendor Name St. Joseph Couni <br />New Vendor ❑ Yes[A No <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE 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 />Asset Exchanae <br />If Yes, Approved by Purchasing <br />Name of Company_ <br />U Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Amount of I I 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 />Dispersal After Approval <br />Todd Skwarcan <br />Jeff Hudak <br />