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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/7/2018 Department Fire <br />BPW Date 3,/13/2018 Phone 9255 <br />Name Andy Myer, A/G EMS <br />0 Legal ❑ Attorney Name Elliott Anderson <br />a) 0, Controller review is required for all Contracts $5,000.00 or more <br />- <br />W Controller F] and greater than one year in length per the City Purchasing <br />E 0 <br />(D a_ -0 CO Policy <br />cl� :3 <br />Purchasing <br />Check the Awroviate Item Tv — Reauired for All Submissions <br />Z <br />Agreement <br />Contract -=P�oposal <br />El Addendum <br />Claim <br />El <br />Bid Opening <br />El <br />Bid Award El Req. to Advertise'] [:1 Title Sheet <br />Quote Opening <br />❑ <br />Quote Award <br />-E] <br />E] <br />Chg Order No. <br />❑ <br />C/O & PCA No. ❑ PC/ A \ <br />Ease./Encroach. <br />El <br />Traffic Control ❑ Resolution <br />❑ <br />Other. <br />Company or Vendor Name <br />St. Joseph Regional Medical Center <br />New Vendor <br />El <br />Yes H <br />No El If Yes, Approved by Purchasing <br />MBENVBE Contractor <br />[j MBE [] WBE <br />Project Name <br />Project Number <br />Funding Source <br />Ca ital Lease Principal <br />Account No. <br />288.0902.42212-24 <br />Amount <br />$ As invoiced <br />Terms of Contract <br />Annual <br />Purpose/Description <br />Supplies EMS with the non -controlled substances, <br />Amount of <br />F-1 <br />� n <br />increase <br />Decrease <br />.. . . ....... <br />Previous Amount <br />Current Percent of Change: <br />$ <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />PO No. <br />........ .. <br />Dispersal After Approval <br />Copy Original <br />