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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />2/20/18 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 2127/18 Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />Legal Attorney Name Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,0OO.O0 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Michael Schmidt <br />U Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE 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 />U Contract U Proposal LJ Addendum <br />❑ Resolution <br />❑ Bid Award Z Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control <br />Required Information <br />U Yes U No U If Yes, Approved by Purchasing <br />f 1 MBE n WBE <br />❑ No ❑ Yes Name of Company <br />Spec C — One (1) or more 2018 or Newer Full Size Cargo Vans <br />2018 Waste Water Capital Budget 642-0630-415.43-02 <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Nan -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of ❑ Increase <br />❑ <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 />❑ <br />❑ <br />Dispersal After Approval <br />Jeff Hudak <br />Al Greek & Sheila Enos & Ken Smith <br />