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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />12/1,8/17 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 12/21/17 Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />Legal Attorney Name Catherine Fanello <br />Controller 0 Controller, review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />[-] Agreement <br />F-1 Professional Services <br />[:1 Bid Opening <br />El Quote Opening <br />Ej Change Order No. <br />El Ease/Encroach. <br />F-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />MBE/VVBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />790TOTSWIN <br />0 Req. to Advertise <br />NMI <br />Truck Centers, Inc. d/b/a Hill Truck Sales <br />ITANNIMIT <br />❑I Title Sheet <br />0 No F1 Yes, Name of Company _ <br />Spec AF — One (1) or More 2017 or Newer Tandem Axle Dump <br />Truck <br />2017 Sewer Department Capital Budget <br />642-0621-415-43-02 <br />$ 207,245.00 <br />Bid Opening Date: 12/21/17 <br />[:1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Amount of L-J Increase <br />El Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />F� <br />F-1 <br />El <br />El <br />9 <br />Dispersal After Approval <br />Jeff Hudak & Sheila Einos <br />Derick Roberts, Dale Helpingstin,e, Terri Swift <br />