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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name ��� �c�P�rtv�n Department C 1 <br />BPW Date Phone Extension <br />as w� <br />..... <br />e Ired Prior to Submittal to Board <br />Attorney <br />Legal Name <br />.... w <br />g � y <br />Controller review is required for all Contract)$5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing F-1 <br />cnecK tnE <br />El Agreement <br />El Professional Services <br />El Bid Opening <br />0 Quote Opening <br />❑ Chg Order No. <br />El Ease./Encroach. <br />F1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />m T .. F a lta for Al/ Submissionsm mm ww <br />�CotntrZ_F­­ <br />❑ Proposal Addendum <br />p ❑ <br />El Amendment <br />Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />E' Quote Award <br />Il C/O & PCA No, <br />❑ PCA <br />❑ Traffic Control <br />R Resolution <br />El Claim <br />Required Information <br />es Yes, pprovedµ �� IT........ <br />by Purchasing <br />No <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE E] No <br />HH 1 97'wa.. C: M1as@PV^" @ 4"1d <br />_._......For ChanggOrders ©n� _...,. m ..:...... ....... ..... Q <br />Amount of <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 />Coy Original <br />