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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />11/22/16 <br />Andrew Myer, Assist Chief/EMS Department Fire <br />BPW Date 12/13/16 Phone Extension 9255 <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 />® Other. <br />Company or Vendor Name Crossroai <br />New Vendor ❑ Yes E <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 />No U If Yes, Approved by Purchasing <br />WBE <br />Yes Name of Company <br />EMS Capital -Equipment Purchases <br />287-0902-422.43-02 <br />$147, 872 <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />El <br />M <br />❑ <br />❑ <br />❑ <br />❑ <br />Andrew <br />Required Contractor's Certification Form Attached (Non- <br />usion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc <br />For Change Orders <br />Dispersal After <br />