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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Amy Shirk Department <br />Admin & Finance <br />BPW Date Phone Extension 9133 <br />Reguired Prior to Submittal to Board <br />�Legal Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller El and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing F] <br />H <br />Agreement <br />H Contract <br />H Proposal L] Addendum <br />El <br />Professional Services <br />El <br />Amendment <br />F-1 <br />Bid Opening <br />El <br />Bid Award <br />❑ Req. to Advertise E] Title Sheet <br />❑ Quote Opening <br />R Quote Award <br />F] Chg Order No. <br />C/O & PCA No. <br />ri f� <br />P A <br />❑ Ease.,/Encroach. <br />❑ Traffic Control <br />esolution -to - - ', 0 <br />[/\--I Other: Disposal <br />Claim <br />Required Information <br />Company or Vendor Name <br />El Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />[:] No <br />1:1 MBE El Yes <br />MBEANBE Contractor <br />Completed E-Verify Form Attached <br />F-1 WBE E] No <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />For Change Orders Only <br />Amount of F-1 <br />n <br />increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />D <br />F <br />F-1 <br />El <br />El <br />F <br />