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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />September 17, .2019...._.........�� <br />Jeff Hudak <br />Department Central Services <br />BpPrW DateFd � ,Se teNmb�er 24, 2019 Phone Extension 574 235-9316 <br />YY#i:mur.; �:=m,-, --. »z2nr�mF�mu '�,r�klkit'0"�u'J0"k.IXJp✓"AtiN�9NN,W�'�NVllp NIMIIPi.1A— fmNFgd <br />o .....�....,. w..�..w..�..w ___......mm.,,� <br />Re uired Prior to Submittalittal to Board <br />Legal Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing <br />Check the4 <br />A <br />Agreement <br />Professional Services <br />El Bid Opening <br />Quote Opening <br />Chg Order No. <br />Ease./Encroach. <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 />Michael Schmidt <br />_ �. <br />pro riate Item Type —Required for All Submissions <br />El Contract 0 Proposal <br />❑ Amendment <br />® Bid Award ❑ Req. to Advertise <br />EI Quote Award <br />F C/O & PCA No. ❑ PCA <br />E] Traffic Control ❑ Resolution <br />❑ Claim <br />.... �.�......................... <br />......... <br />Required Information formation <br />Addendum <br />❑ Title Sheet <br />n Yes If Yes, A roved "....._....,......._."...._� <br />� pp by Purchasing <br />No <br />WBECompleted E-Verify Form Attached Nos <br />Spec T — One (1) Or More 2019 or Newer 4x4 Crew Cab <br />Concrete Trucks <br />Sewer Department <br />750-0621-792.43-02 <br />$57,680.00 <br />For char ee Qriers On w������ �........... <br />_ .....! ......eee ...... <br />�... �.... <br />Amount of ❑ Increase -$ .......... mm <br />El Decrease <br />$ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />Jeff Hudak <br />®El <br />Terri Swift <br />