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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2016/08/24 <br />Name Rene Casiano Department <br />IT <br />BPW Date 2016/09/13 Phone Extension 5897 <br />Re uired 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 />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 />® Other: Renewal <br />Required Information <br />Company or Vendor Name Esri <br />New Vendor ❑ Yes F <br />MBE/WBE Contractor ❑ MBE [ <br />MBE/WBE Contractor Requested ❑ No <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 />Previous Amount <br />Increase <br />Decrease <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />No <br />WBE <br />It Yes, Approved by Purchasing <br />Yes Name of Company <br />Required Contractor's Certification Form Attached (Non- <br />lusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc <br />For Change Orders On <br />Dispersal After Approval <br />