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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />7/28/16 <br />Corbitt Kerr <br />Department Public Works <br />BPW Date 8/9/16 Phone Extension 5931 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />Check the Appropriate Item Type — Required for All Submissions <br />® Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />F1 Other: <br />Company or Vendor N <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />MACOG <br />Yes No ❑ If Yes, <br />] MBE ❑ WBE <br />FYI Traffic Count MOU <br />116-075 <br />LRSA - Professional Services <br />251-0608-431.31-06 <br />$ 5000 <br />Traffic Count Data collected by MACOG for City of South Bend <br />❑ Required Contractor's Certification Form Attached (Non - <br />I Required For Change Orders Only <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />7 <br />