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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date June 18, 2019 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date June 25, 2019 Phone Extension 574-235-9316 <br />iwu�w�w��imun,��mc��uurmaw.m��rm�md�wm�unr�ummu�^AmmuiuuuumHUHUHuuum�;i�vui�umr�nawo�tiw�ivinwyrwwaa��,.a �.v.�rva�mnvr✓,n�av,a�;�=a,,�,:.�—.�--;.�„�r,,��r�r�uurraucsww¢�itt✓fmxw� ���r�au.rmr�vr��+i:!a�. .__ r—,.mow. — ,�;e�r'.� u�ur. w�aus,w!ia <br />Required Prior to Submittal to Board <br />Purchasing ® Michael Schmidt <br />............................................................................ <br />Check the <br />1__]I Agreement <br />El Professional Services <br />0 Bid Opening <br />El Quote Opening <br />E] Chg Order No. <br />Ease./Encroach. <br />F-1 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 />iropnate Item Type - <br />Contract <br />❑ Amendment <br />❑ Bid Award <br />❑ Quote Award <br />FC/O &PCANo. <br />_ <br />❑ Traffic Control <br />d for All Submissions <br />] Proposal <br />® Req. to Advertise <br />Required Information <br />PCA <br />Resolution <br />Claim <br />Addendum <br />❑ Title Sheet <br />-�._... -1-- .... —.- <br />0 es ❑ If Yes, Approved- <br />Purch........ Y... <br />asing .� .._._ . <br />[� No <br />MBE Completed E-Verify Form Attached El Nos <br />WBE <br />oec R Twen (. ) f Boxes <br />t Noe 29 More or Less Brand New Lea <br />Department - Capital Lease & Interest <br />Street......��................_......�........- �.��.. <br />202-0607-431.38.01 & 202-0607-431.38.02 <br />Opening Bid Date: July 23, 2019 <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change, <br />New Amount $ <br />................................ <br />Total Percent of Change: <br />Time Extension: <br />.............................. <br />Copy Original <br />® ❑ Jeff Hudak <br />® ❑ Terri Swift <br />® Sean Ward <br />Dispersal After Approval <br />