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BOARD OF PUBLIC WORI(S <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />BPW Date <br />Legal <br />Controller ❑ <br />Purchasing ❑ <br />HAgreement Amendment <br />Professional Services <br />Bid Opening <br />F-1 Quote Opening <br />R Change Order No, <br />F-1 Ease/Encroach. <br />F-1 Other: <br />Company or Vendor Name <br />Department <br />Division/Bureau po <br />. . . ......... <br />Phone Extension . . . . . .... . . <br />Attorney Name: <br />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 />L] Contract <br />F-1 Resolution <br />F-1 Bid Award <br />F-1 Quote Award <br />❑C/O & PCA No <br />Traffic Control: <br />New Vendor - <br />MBE/ VBE Contractor <br />MBEIWBE Contractor Requeste( <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Yes [>14N <br />E:1 Req. to Advertise <br />F-1 PGA. <br />001110ri <br />El Title Sheet <br />If Yes, Approved by <br />LJ'Require O Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of E] increase $ <br />[:] Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Chanqe-. <br />Copy <br />Original <br />1:1 <br />❑ <br />F-1 <br />El <br />El <br />1:1 <br />