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Date <br />Name <br />BOARD OF PUBLIC WORDS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 12. 2018 <br />Jeff Hudak <br />Department Central Services <br />BPW Date March 27, 2018 Phone Extension 574-235-9316 <br />Required Prior to Submittal. to` Board <br />Legal ® Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ® <br />Michael Schmidt <br />Check'the Appropriate <br />.. <br />Item T ` e m- Re uired for All Submissions <br />❑ Agreement <br />❑ Contract ❑ Proposal <br />❑ Addendum <br />❑.Professional Services <br />❑ Bid Opening <br />❑ Bid Award ® Req. to Advertise <br />❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease,/Encroach. <br />❑ Traffic Control ❑ Resolution <br />❑ Other <br />❑ Claim <br />-A <br />Required information <br />Company or Vendor Name <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />MBEIWBE Contractor <br />❑❑ MBE Completed E-Verify Form Attached <br />WBESpec <br />❑ NQs <br />K - One (1) or more 2018 or Newer 1.0 Cubic Yard <br />Project Name <br />Load erslBackhoes <br />Project Number, <br />2018 Water Works Capital Budget 622-0640-415-43-02 <br />Funding Source <br />_ <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Bid Opening Date: <br />For Chan g e'0rders O61 <br />Amount of ❑ increase $ <br />❑ Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change. <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />PO No. <br />Dispersal After Approval <br />Copy Original <br />® ❑ Jeff Hudak <br />® ❑ Ed Herman <br />❑ ❑ <br />