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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />March 20. 2018 <br />Michael Schmidt <br />Purchasing <br />Michael Schmidt <br />Department Central Services <br />Check the Appropriate.1tern <br />T e — Re <br />aired for All Submissions <br />® Agreement <br />❑ Contract <br />❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Amendment <br />❑ Bid Opening <br />❑ <br />Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Chg Order No. <br />❑ <br />CIO & PCA No. <br />❑ PCA <br />❑ <br />Ease./Encroach. <br />❑ <br />Traffic Control <br />❑ Resolution <br />n <br />Other: <br />❑ Claim <br />Company or Vendor Name <br />New Vendor <br />MBEIINBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Re' wired' information` <br />Brandeis Machinery & Supply Company <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />❑ B E Completed E-Verify Form Attached ❑Nos <br />Special Purchase under IC 5-22-10-5 of a Demo Milling Machine <br />Capital Lease Fund 750 Street Department <br />Amount $435,000 <br />Terms of Contract <br />Purpose/Description <br />For Chan e Orders Or <br />Amount of ❑ increase <br />$ <br />❑ Decrease <br />$ <br />Previous Amount $ <br />Current Percent of Change. <br />% _ <br />New Amount $ <br />Total Percent of Change: <br />% <br />Time Extension: <br />Dispersal After Approval <br />Copy Original <br />❑ ® Jeff Hudak <br />❑ ® Derlck Roberts <br />❑ ❑ <br />