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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/08/2017 <br />Name <br />Amy Shirk, Senior Budget Analyst <br />Department <br />Admin & Finance <br />-BPW Date <br />12/21/2017 <br />Phone Extension <br />9 1'33 <br />Legal ❑ Attorney Name <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />LJ Agreement LJ1.,0ontract ❑ Proposal ❑] Addendum <br />❑ Professional Services Resolution <br />F-1 Bid Opening ❑ Bid Award E:1 Req. to Advertise Title, Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PGA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />M Other: Disposals <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBEANBE Contractor <br />❑ MBE ❑ WBE <br />MBENVBE Contractor Requested ❑ No ❑ Yes Name of Company_ <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non- <br />Co[lusion, Non -Discrimination, Non -Debarment, E-Ver,ify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ increase $ <br />❑ Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />