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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />8/25/17 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 9/12/17 Phone Extension 574-235-9316 <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <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 />H Contract jJ Proposal U Addendum <br />❑ Resolution <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑C/O &PCANo. ❑PCA <br />❑ Traffic Control <br />Required lnfo;rmation <br />El Yes No If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec AA -- Two 2) more or less 2017 or Newer Utility Crew Trucks <br />2017 Sewer Department Capital Budget <br />642-0621-415-43-02 <br />Ra <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran, etc. <br />Amount of ❑ Increase $ <br />❑ Decrease $ <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 />❑ <br />❑ <br />EP, J <br />% <br />Dispersal After Approval <br />Jeff Hudak & Sheila Enos <br />Derick Roberts, Dale Helpingstine, Terri Swift <br />