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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 1/27/17 <br />Name Matt Chlebowski Department Central Services <br />BPW Date 2/14/17 Phone Extension 574-235-9316 <br />Legal ® Attorney Name Michael Schmidt <br />review is required for all Contracts $5,000.00 or more and <br />Controller El greater <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />Check the Appropriate <br />Item Type —Required for All Submissions <br />Agreement I <br />Contract ❑ Proposal El Addendum <br />❑ <br />❑ <br />Professional Services ❑ <br />Bid Opening ❑ <br />Resolution <br />Bid Award ®Req. to Advertise ❑Title Sheet <br />❑ <br />❑ <br />Quote Opening ❑ <br />Change Order No. ❑ <br />Quote Award <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ <br />Traffic Control <br />F-1 <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <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 />❑ Yes ❑ No ❑ If Yes Approved by Purchasing <br />F-1 MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec — (D)1 or more or less 2016 or newer 28 cubic yard single <br />arm side loading refuse truck <br />2017 Solid Waste Capital Lease Principal 611-0610-415-37-11/ <br />Interest 611-0610-415-3712 <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment E-Verify, Iran, etc <br />Increase <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Dispersal After Approval <br />Matt Chlebowski & Sheila Enos, Central Services <br />Mike Bronstetter & Carol Kurzhal, Solid Waste <br />