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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />2/22/18 <br />Jeff Hudak <br />Department Central Services <br />❑ Agreement <br />❑ <br />Contract La Proposal Lj Addendum <br />❑ Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control <br />❑ Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBEIWBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Spec D — One (1) or more 2018 or Newer 3/ Ton Four Wheel Drive <br />Project Name <br />Pick Up Trucks <br />Project Number <br />Funding Source <br />MVH — 202-0607-431-3711 & 3712 <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders O;rl <br />Amount of ❑ increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />X <br />Dispersal After Approval <br />Jeff Hudak & Terri Swift <br />