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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW RE' QUEST FORM <br />Date December 15, 2017 <br />Name George King Department Admin/Finance <br />BPW Date December 21, 2017 Phone Extension 9977 <br />Required Prior to Submittal to Board <br />Legal Attorney Name <br />xx Controller review is required for all Contracts $5,000.00 or more <br />Controller r-1 and greater than one year in length per the City Purchasing <br />Policy <br />xx <br />Purchasing r— <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Chg Order No. <br />R Ease./Encroach. <br />F1 Other: <br />LJ Contract LJ Proposal <br />F-1 Amendment <br />Bid Award Req. to Advertise <br />Quote Award <br />C/O & PCA No. �PCA <br />Traffic Control xxF] Resolution <br />[] Claim <br />Addendum <br />Title Sheet <br />ow I <br />Required Information <br />Company or Vendor Name <br />N/A <br />New Vendor <br />El Yes E] If Yes, Approved by Purchasing <br />F-1 No <br />MBE/WBE Contractor <br />F-1 mBE Completed E-Verify Form Attached <br />R WBE <br />El Yes <br />No <br />Project Name <br />Old Cell Phone Disposal <br />Project Number <br />Funding Source <br />N/A <br />Account No. <br />Amount <br />N/A (Free Service) <br />Terms of Contract <br />Purpose/Description <br />Dispose of old cell Phones ( approx. 95 each) in an <br />environmentalIy friendly -manner to site at <br />http://www.stiosephcountyindiana.com/1 98/Household- <br />Hazardolus-Waste <br />Amount of F-1 increase $ <br />[:] Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />George King Admin/Central @ Central <br />Dave Qualls, Sr. Central <br />Original <br />F-1 <br />xxF1 <br />xxF-1 <br />R <br />0 <br />El <br />