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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 4-1-19 <br />Name ....Scott Horvath.._.�.�......�._�...���_...�._.._�..........._�___.....____W..��.......� <br />Department Water <br />BPW Date 4-9-19 Phone Extension 574-235-5665 <br />Req��q d Prior to Submittal to Board <br />BPW Attorneys Attorney Name <br />Dept. Attorney Z Attorney Name <br />Purchasing z <br />Check the Appropriate Item �l ,)e _ Re�r i <br />Professional Services Agreement ❑ Contract <br />❑ Open Market Contract Amendment/Addendum <br />❑ Bid Opening Bid Award <br />Quote Opening ❑ Quote Award <br />EJ Proposal Opening C/O & PCA No. <br />❑ Chg. Order, No. Traffic Control <br />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 />it ed l r All Submissions <br />Information <br />Ll Proposal <br />El Special Purchase, QPA <br />Ej Req. to Advertise <br />Reject Bids/Quotes <br />PCA <br />E] Resolution <br />Fj Ease./Encroach <br />❑ Title Sheet <br />ME Simpson <br />Yes If YesApproved <br />❑ , pp by Purchasing <br />® No <br />MBE ❑ WBE Completed E-Verify Form Attached ❑ Nos <br />South Bend Water Leak Survev <br />For C:liant e Orders On <br />Amount of ❑ Increase $ <br />Decrease ($ ) <br />Previous Amount $ <br />..... .................................... <br />_......___ <br />Increase % <br />Current Percent of Change: Decrease _.:.. mmmmmmmm_...% <br />New Amount $ <br />Increase % <br />Total Percent of Change: Decrease Q'wwww ho)�wmwwwwwwwww <br />Time Extension Amount: <br />w Completion Date: Ne ._._.. .._..._. _ ._................_...... __ ... . <br />