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BOARD OF PUBLIC WORKS <br />AGENDA <br />ITEM REVIEW REQUEST FORM <br />Date 22 Aug 2016 <br />Name Cecil Eastman <br />Department Admin Fin <br />BPW Date 13 Sep 2016 <br />Phone Extension 9317 <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller ® <br />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 <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑Contract / t, ❑ Proposal ❑Addendum <br />❑ <br />Professional Services <br />❑ Resolution l"S L <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: Asset Disposal <br />Required Information <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No [ <br />MBEM/BE Contractor ❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ❑ No ❑ Yes <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount $ <br />Terms of Contract <br />If Yes, Approved by Purchasing <br />Name of Company <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Onlv <br />Amount of ❑ Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />After Approval <br />Copy <br />Original <br />❑ <br />® Cecil Eastman <br />® <br />❑ Mary Wisniewski <br />❑ <br />❑ <br />