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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />11 /06/2018 <br />Shirk <br />Department Admin & Finance <br />BPW Date 11/13/2018 Phone Extension 9133 <br />WIIIYfNFlililM NNW II�I'BVMfipf@V���+�pP^�{�" ININIfmW"`k�,Y'�"1�'IIIWVl1V"&'I�WIVIIVEb'�45,1k^'� w'�ieR „�dWl�°"L�Y ��e ttiY�IIWK'�a��wy�gMRM�1��IftVIMIBrvN�� 5':NPNS� <br />F�e�uired Pnor to Submittal to Board <br />Legal Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ❑ <br />Check the P <br />Agreement <br />El Professional Services <br />Bid Opening <br />F1 Quote Opening <br />E] Chg Order No. <br />❑ Ease./Encroach. <br />Other: Disposal <br />)ropriate ItemITTv <br />Contract <br />❑ Amendment <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O &PCANo. <br />❑ Traffic Control <br />Company or Vendor Name <br />New Vendor F Yes <br />❑ No <br />MBE/WBE Contractor ❑ MBE <br />EJ WBE <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />uired for All Submissions <br />[� Proposal Addendum <br />❑ Req. to Advertise ❑ Title Sheet <br />uired Information <br />PCA <br />esolutioncb > )O 5 <br />Claim <br />If Yes, Approved by Purchasing <br />Completed E-Verify Form Attached ❑ Yes <br />❑ No <br />....... _ - __. -- <br />ITITITITIT w w For Change Orders Only <br />Amount of 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 />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />