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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />March 1, 2018 <br />Jeff Hudak <br />Department Central Services <br />❑ Agreement <br />❑ <br />Contract ❑ Proposal LJ Addendum <br />❑ Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Requirec! Information <br />Company or Vendor Name <br />New Vendor <br />❑ <br />Yes ❑ <br />No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ <br />MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Spec F — One (1) or more 2018 or Newer Mid -Size Extended Cab <br />Project Name <br />Four Wheel Drive Pick Up Truck <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />2018 Code Enforcement Capital 2017 Capital Lease account <br />number 750-0000-413-4302 <br />F <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached {Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount . $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Jeff Hudak <br />® ❑ Randy Wilkerson <br />❑ ❑ <br />