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PAN 0191 IKIG I I GWROVA 5 ZH AVA I I <br />Jeff Hudak <br />Department —Central Services <br />BPW Date April 24, 2018 Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />Legal Z Attorney Name Clara McDaniels <br />Controller ❑ Controller review is required for, all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing Z Michael Schmidt <br />Check the Appropriate Item Type — Required for All Submissions <br />F-I Agreement ' ❑ Contract F Proposal El Addendum <br />F Professional Services El Resolution <br />F Bid Opening El Bid Award Z Req. to Advertise EJ Title Sheet <br />F Quote Opening El Quote Award <br />E] Change Order No. F-I C/O & PGA No. ❑ PCA <br />El Ease/Encroach. El Traffic Control <br />El Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE 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 />2 =-0 I rano romn M-It <br />Nm Ell 031191YU-10 NORMAN <br />0 No El Yes Name of Company _ <br />Spec Q — Two, (2) more or less 2018 or Newer Refurbished Medic <br />Units <br />.41-1 <br />F-I Required Contractor's Certification Form Attached (Non <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Reruired; For Change Orders C►rply <br />Amount of El increase $ <br />El Decrease $ <br />Previous Amount <br />Current Percent of Change: % A nn ei <br />New Amount <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original . . ........ <br />M F-I Jeff Hudak <br />F-I Todd Skwarcan & Andy Myer <br />