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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Mav 11, 2018 <br />Jeff Hudak <br />H Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />F] Other: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBEIWBE 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 />El <br />Department Central Services <br />❑ No ❑ Yes Name of Company <br />Spec C -- One 1 or more 2018 or Newer Full Size Cargo Vans <br />2018 Waste Water Capital Budget 642-0630-415.43-02 <br />$ 29,866.00 <br />A'.J <br />g Date: <br />❑ Required Contractor's Certification Form Attached {Non - <br />Collusion, Nan -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />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 />Jeff Hudak <br />D�D <br />Dispersal After Approval <br />Al Greek & Sheila Enos & Ken Smith <br />