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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date July 7. 2016 <br />Name Rick Smigielski Department Environ Services <br />BPW Date Tuesday, July 26, 2016 Phone Extension 5889 <br />Required Prior to Submittal to Board <br />Legal Attorney Name Michael Schmidt <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 Carol Kurzhal <br />Check the Appropriate Item Type — Required for All Submissions <br />Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />Professional Services <br />Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Chg Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease./Encroach. ❑ Traffic Control ❑ Resolution <br />❑ Other: ❑ Claim <br />Required Information <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 />Ll Yes ❑ If Yes, Approved by Purchasing <br />® No <br />❑ MBE Completed E-Verify Form Attached ❑ Yes <br />❑ WBE ❑ No <br />Annual RT-DSS Service Agreement <br />Monthly fixed fee plus T&M not to exceed <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />