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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />June 5, 2018 <br />Andrew Netter <br />Department DCI <br />Division/Bureau Planning <br />X Agreement Amendment <br />❑ Contract ❑ Proposal ❑ 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 />❑ Traffic Control: <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑ <br />L,j Yes ❑ No ❑ If Yes, Approved by <br />_Purchasing <br />� MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />$82'i '00 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />