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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 $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />® <br />Agreement <br />❑ Contract ❑ Proposal ❑Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />MACOG <br />New Vendor <br />0 Yes ❑ No If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ® WBE <br />Project Name <br />FYI Traffic Count MOU <br />Project Number <br />116-075 <br />Funding Source <br />LRSA - Professional Services <br />Account No. <br />251-0608-Ul.31-06 <br />Amount <br />$ 5000 <br />Terms of Contract <br />Purpose/Description <br />Traffic Count Data collected by MACOG for City of South Bend <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />ired For Change Orders <br />Amount of I I Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />ispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />