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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />01/16/19 <br />Div. Chief Tim Lancaster <br />Department SBPD <br />BPW Date 02/12/19 Phone Extension 9301 <br />.........._..........._m......Required <br />..........................�.......... .... ........................ <br />._._.............................. <br />_ <br />Legal ® Attorney Name Stephanie Steele/Clara McDaniels <br />Controller ® Controller review is required for all Contracts $5,000.00 or more anc <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the appropriate Item Type Required for All Submissions <br />Agreement <br />H <br />Contract 0 Proposal Addendum <br />El Professional Services <br />F1 <br />Resolution <br />[] Bid Opening <br />F] <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />El Quote Opening <br />[l <br />Quote Award <br />Change Order No. <br />0 <br />C/O & PCA No. ❑ PCA <br />El Ease/Encroach. <br />E] <br />Traffic Control <br />® Other: State of Indiana <br />QPA No. 16142 w/ Kiesler <br />Police Supply, Jeffersonville, <br />I130 47--- <br />m_...............m._ ... _...._............____...w...........�- m <br />Required Information <br />Company or Vendor Name Kiesler's Police Su <br />New Vendor ❑ Yes Z No If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE R WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name South Bend Police Department Ammunition Purchase <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Other operatingmsuppliesmm ....... <br />101-0801-421-22-24 <br />.................................................................................... <br />$35,924.34 <br />curchase der)artment duty and trainina ammunition, <br />[-1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Ver!fy, Iran, etc.) <br />Reauir d For 'Chah e Ordlers, OnI <br />Amount of Increase <br />[] Decrease <br />Previous Amount $ <br />Current Percent of Change: _..... % <br />New Amount $ .ww............� w........®...w_ �.......� <br />Total Percent of Change:.�..._..__%....._............. ...... ........._.................................._ <br />Dispersal After Approval <br />Copy Original <br />® ❑ Div. Chief Tim Lancaster <br />.................................�.�.�............�.�.�....�.�_. _ w.....�........................ <br />.._......... <br />�....�..0 <br />❑ ❑ <br />El ❑ <br />