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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />June 1. 2018 <br />Jeff Hudak <br />Purchasing <br />L J Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. _ <br />❑ Ease/Encroach. <br />FI Other: <br />® Michael Schmidt <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 />❑ Contract ❑ Proposal <br />n Resolution <br />® Bid Award ❑ Req. to Advertise <br />❑ Quote Award <br />❑ CIO & PCA No. ❑ PCA <br />❑ Traffic Control <br />G�+.-li _11 <br />❑ Title Sheet <br />❑ Yes ❑ No LJ If Yes, Approved by Purchasing <br />n MBE F WBE <br />❑ No ❑ Yes Name of Company <br />Spec Q -- Two (2) more or less 2018 or Newer Refurbished Medic <br />Units <br />2018 Fire Department Capital Budget 287-0902-422-4302 <br />$ 352.826.00 <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -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 />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Jeff Hudak <br />Todd Skwarcan & Andy Myer <br />