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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />02/21 /2017 <br />Michael Schmidt <br />Department Legal <br />BPW Date 02/23/2017 Phone Extension <br />Required Prior to Submittal to Board <br />Legal Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Chg Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease./Encroach. ❑ Traffic Control ❑ Resolution <br />❑ Other: ❑ Claim <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <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 />rNi <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />❑❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Special Rate Agreement <br />No cost revision to page 1 of agreement previously approved by <br />Board of Works on 2/14/17 <br />For Chanoe Orders O <br />Increase <br />Decrease $ ArrAUVED <br />$ ""rd uf ipuNic Works <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />7 <br />