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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />7/17/2018 <br />Matt Chlebowski <br />Department Central Services <br />BPW Date 7/24/2018 Phone Extension 574-235-9316 <br />Required Prior to Submitta[10 Board <br />Legal ❑ Attorney Name Catherine Fanello <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 <br />❑ Michael Schmidt <br />N Agreement <br />U Contract L] Proposal LJ Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBENVBE Contractor <br />Req uested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Teamsters Local 364 <br />U Yes N No L,j If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />® No ❑ Yes Name of Company <br />Spec —Memorandum of Understanding <br />(subject to funding) <br />222-0605-419-1002 <br />Bid Opening Date: <br />Proposing to change the shift differential for the E ui ment Services <br />Mechanics from forty-five cents to one dollar -fifty cents per hour <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 />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />