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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12-12-19 <br />Name Kim Thompson Department Utilities <br />BPW Date 12-19-1.9 Phone Extension 5969 <br />Realuited Prior to Submittal to Board <br />. �.... ..__ ...... <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney n <br />Purchasing ❑ <br />Check the <br />Attorney Name <br />Item <br />U Professional Services Agreement LJ Contract <br />Open Market Contract <br />Amendment/Addendum <br />Bid Opening <br />Bid Award <br />Quote Opening <br />❑ Quote Award <br />❑ Proposal Opening <br />C/O & PCA No. <br />EJ Chg. Order, No. <br />❑ Traffic Control <br />Other: Water System <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 />Information <br />All Submissions <br />LJ Proposal <br />F Special Purchase, QPA <br />❑ Req. to Advertise <br />Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />❑ Title Sheel <br />Yes If....,... .......__........._.w... <br />Yes, Approved by Purchasing <br />No <br />0MBE Completed E-Verify Form Attached ❑ Yes <br />R WBE ❑ No <br />Request for BPW to identify certified operators for water system as an <br />Indiana Department of Environmental <br />Management <br />For Chan a Orders Qnl�- .. <br />Increase $ <br />Amount of _.. _ ._ ................ _... . ....... <br />....__..............._ <br />Decrease ($ ) <br />Previous Amount $ <br />Increase % <br />Current Percent of Change: Decrease ( %) <br />New Amount $ <br />Increase % <br />Total Percent of Change: Decrease __. %) <br />Time Extension Amount: <br />New Combletion Date: <br />