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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date d ......... -2 -_ y-,20 <br />Name Amy Shirk Department Admin & Finance <br />Purchasing <br />Check the p <br />H Agreement <br />❑ Professional Services <br />[� Bid Opening <br />Quote Opening <br />Chg Order No. <br />El Ease./Encroach. <br />Other: Disoosl <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />riate Item TVDe — <br />LJ Contract <br />El Amendment <br />El Bid Award <br />Quote Award <br />E C/O & PCA No. <br />Traffic Control <br />for All Submissions <br />Proposal R Addendum <br />❑ Req. to Advertise ❑ Title Sheet <br />PCA <br />Resolution U <br />If I Claim <br />uired Information <br />El Yes �] If Yes, Approved by Purchasing <br />❑ No <br />1:1 MBE Completed E-Verify Form Attached ❑ Yes <br />❑ WBE ❑ No <br />For Change Orders Only <br />Increase $ <br />Amountof _._...... _....................... __._ .................... <br />El Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />El <br />❑ <br />F <br />❑ <br />