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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />11 /19/2018 <br />Shirk <br />Department Admin & Finance <br />BPW Date 12/11/2018 <br />Phone Extension 9133 <br />�_........................... ._.......... <br />......Wvvvvv_vv <br />_ ____ W.._... <br />Required Prior to Submittal to Board <br />..__ .._ ............ <br />Legal <br />Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ <br />and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing <br />Check the Appropriate <br />Item Type.—.e uire for All Submissions <br />Agreement <br />F-1 <br />Contract n Proposal E Addendum <br />Professional Services <br />Amendment <br />[� <br />Bid Opening <br />❑ Bid Award El Req. to Advertise ❑ Title Sheet <br />Quote Opening <br />❑ Quote Award <br />Chg Order No. <br />❑ C/O & PCA No. <br />PCA <br />Ease./Encroach. <br />❑ Traffic Control <br />RkesolutionUZ <br />Other: Disposal <br />Claim <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />0 Yes El If Yes, Approved by Purchasing <br />❑ No <br />MBE/WBE Contractor <br />❑ MBE Completed E-Verify Form Attached <br />❑ WBE <br />El Yes <br />No <br />Project Name <br />Project Number <br />Funding Source <br />..__........... <br />Account No. <br />�...._....... <br />Amount <br />....... . . .............................. . <br />Terms of Contract <br />Purpose/Description <br />............................................. ........ <br />wW <br />_..... ... ....__... <br />For Chance Orders Only <br />Amount of LJ 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 />