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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW RE QUEST FORM <br />Date 112/13/2017 <br />Name <br />Amy Shirk, Senior lqudqp�t Analyst <br />Department <br />Admin & Finance <br />BPW Date- <br />12/21/2,017 <br />Phone Extension <br />9133 <br />Legal D Attorney Name <br />Controller 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 />Purchasing ❑ <br />F_ Check the Appropriate Item Type - Re jeked forAll Submissions <br />[:1 Agreement In Contract El Proposal El Addendum <br />F-1 Professional Services kesollutio" <br />F1 Bid Opening Bid Award El Req. to Advertise El Title Sheet <br />❑ Quote Opening Quote Award <br />❑ Change Order No. ❑ C/O, & PCA INo. ❑ PCA <br />E] Ease/Encroach. ❑ Traffic Control <br />M Other: Disnosals. <br />Company or Vendor Name <br />New Vendor F1 Yes [-] No I <br />MBE/VVBE Contractor F-1 MBE [] WBE <br />MBENVBE Contractor Requested 0 No n! Yes <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Puroose/Descriotion <br />If Yes, Approved by Purchasing <br />Name of Company <br />F-1 Required Contractor's Certification Form Attadhed (Non- <br />Collusiion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc, <br />Amount of El increase $ <br />n Decrease $ <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 />F-1 <br />F-1 <br />F-1 <br />n <br />El <br />El <br />