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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/06/19 <br />Name Alicia Czarnecki Department Erg ��in+ecrin <br />BPW Date 08/13/19 Phone Extension 5903 <br />IMo Vpwla uuuuu my i uuuu u 338iSAi�.➢!3?d]G?IP.Zi;22"d'�3i�N,�W .V'H+E"£i..i AO AWIXI;F,PNilmfida& <br />Required Prior to Submittal to Board <br />BPW Attorney Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing 1:1 <br />......._._.........Check.the A tq�riate Item T e rl <br />Professional Services Agreement ❑I Contract <br />Open Market Contract ❑ Amendment/Addendum <br />❑ Bid Opening ❑ Bid Award <br />Quote Opening ❑ Quote Award <br />❑ 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 />Amount of <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Information <br />All Submissions <br />Proposal <br />�] Special Purchase, QPA <br />E] Req. to Advertise <br />Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />[� Ease./Encroach <br />Jones Petrie Rafinski Co�oratson O11 <br />Increase % <br />Decrease i % <br />❑ Title Sheet <br />Increase % <br />Total Percent of Change: Decrease �( %) __ w............................................................... <br />Time Extension Amount: <br />................... <br />New Completion Date: <br />