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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 03/12/2019 <br />....... . <br />Name AmyShirk Department Admin & Finance <br />Purchasing ❑ <br />Check the A <br />LJ Agreement <br />R Professional Services <br />E] Bid Opening <br />Quote Opening <br />❑ Chg Order No. <br />❑ Ease./Encroach. <br />M Other: DisDosal <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 />)roe riate Item T Required for All Submissions <br />Contract FJProposal ❑ Addendum <br />LJ Amendment <br />El Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />�] Quote Award <br />C/O &PCANo. ❑ A. <br />(� Traffic Control Resolution I�Q _ 3 �I j <br />...... <br />Claim �/ I <br />Reulred Information <br />.... ....a .. ................ <br />❑ Yes If Yes, Approved by Purchasing <br />EJ No <br />MBE Completed E-Verify Form Attached El Yes <br />❑ WBE ❑ No <br />For Cha�ut�0 Orders Only <br />Amount of El Increase $ <br />Q Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />................. <br />New Amount $ <br />Total Percent of Change: _..... <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />El <br />