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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/29/18 <br />Name Michael Schmidt <br />Department Admin/Finance/ <br />Purchasina <br />BPW Date 7/10/18 Phone Extension 574-235-9316 <br />[ j Agreement <br />LJ Contract U Proposal H Addendum <br />❑ Professional Services <br />® Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control <br />I-1 <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE 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 />[1 Yes [1 No U If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Ell <br />Resolution 33-2018. Approving the Policy for Online Reverse <br />Auctions <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc. <br />Amount of ❑ Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />$ <br />