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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/7/2018 Department Fire <br />BPW Date 6/26/2018 Phone 9255 <br />Name Todd Skwarcan, A/C Services <br />0 Legal Attorney Name Elliott Anderson <br />-0 4- <br />a) 2 <br />0 — -2 Controller review is required for all Contracts $5,000.00 or more <br />4- <br />'- :t-- m Controller and greater than one year in length per the City Purchasing <br />0-.2 <br />P CO) CL -0 CO Policy <br />0� :3 <br />Purchasing Z Michael Schmidt <br />('hor.k fhp. Annrnnri:afp lfp.m Tvnp - Rpoifired for All Sul mhczsinnq <br />Z <br />Agreement <br />Contract <br />U Proposal <br />El Addendum <br />❑ <br />❑ <br />❑ <br />Claim <br />Bid Opening <br />Quote Open <br />E] Bid Award Req. to Advertise ❑ TitleSheet <br />Quote Award <br />❑ <br />El <br />Chg Order No. <br />Ease./Encroach. <br />El <br />C/O & PCA No. <br />Traffic Control <br />❑ PCA <br />Ej Resolution <br />El <br />Other: <br />Required Information <br />Company or Vendor Name <br />Public Safety Medical <br />New Vendor <br />E]Yes <br />Z <br />No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />Project Name <br />❑ MBE [:] WBE <br />Project Number <br />Funding Source <br />Fire Personnel Services-Benefits/Medical <br />Account No. <br />101,0901.422.31-06 <br />Amount <br />$ Per Agreement- as invoiced <br />Terms of Contract <br />Purpose/Description <br />2018 Service Agreement; Firefighters' exams/annual physicals <br />Amount of <br />❑ <br />❑I <br />Increase <br />Decrease <br />$ <br />$ <br />Previous Amount <br />Current Percent of Change: <br />$ <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />PO No. <br />Dispersal After Approval <br />Copy Original <br />n n <br />n El <br />