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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/0212018 <br />Name Amy Shirk, Senior Budget Analyst Department Admin & Finance <br />BPW Date Phone Extension 91133 <br />Legal ❑ Attorney Name <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing El <br />LJ Agreement <br />H Contract LJ Proposal L] Addendum <br />F] Professional Services <br />n Resolution <br />❑ Bid Opening <br />n Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />Ell Quote Opening <br />F-1 Quote Award <br />El Change Order No. <br />0 C/O & PCA No. ❑ PCA <br />El Ease/Encroach. <br />F-1 Traffic Control <br />Other-, Disposals <br />Required Information! <br />Company or Vendor Name <br />New Vendor <br />El Yes El No 0 If Yes, Approved by Purchasing <br />MBENVBE Contractor <br />[:] MBE E] WBE <br />MBEANBE Contractor Requested n No F-1 Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Nan -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change, Orders <br />Only <br />Amount of ❑ increase $ <br />El Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />1:1 El <br />F-1 F-1 <br />n El <br />