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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 9/7/2018 <br />❑ Agreement <br />❑ Contract L] Proposal a Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />® <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />I-1 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 />Horton Emergency Vehicles <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />r-1 MBE n WBE <br />❑ No ❑ Yes Name of Compan <br />Spec S - Award for One (1) more or less 2018 or newer emergency <br />medical vehicle <br />287-0902-421.43-02 <br />$ 259,760 <br />Award One more or less 2018 or newer Emergency Medical Vehicle <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />R, e' glre. for Change Ordersr�1yElm <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 Original <br />® ❑ Andy Myer; Jeff Hudak <br />❑ ❑ <br />❑ l ❑ <br />