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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 4/10/19 <br />Name Jeff Hudak Department Central Services <br />BPW Date 4/25/17 Phone Extension 574-235-9316 <br />Her m��W�rtm R,ufia��aa <br />Re uired Pnor to Sub _....... ...._� .... <br />mittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />Check the <br />Lj Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />E] Change Order No. _ <br />El Ease/Encroach. <br />E Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE 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 />)ropriate ItemType - <br />Contract <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />E C/O & PCA No. _ <br />❑ Traffic Control <br />for All Submissions <br />Proposal <br />® Req. to Advertise <br />Required Information <br />❑ PCA <br />Yes LJ No Jj If Yes„ Approved by Purchas <br />MBE F� WBE <br />rOS-oe .0 <br />❑ Title Sheet <br />No ❑ Yes Name of Compaq <br />Spec . ......................... <br />N — One (1) or more 2019 or Newer LP Powered Lift Truck <br />201....9 Equipment Services Capital Lease Budget <br />.... <br />224-0605-419 3801 Principal 224-0605 419-3802 Interest <br />... _...__ ............................. <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non- <br />_. er <br />... � ollusion,wwNon-Discrimination, Non -Debarment, E-V_ww , Iran, etc. <br />uwre _ __,....� <br />e�,! o han e O Orders .... <br />Amount of El Increase $ <br />Fj Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ w...._....... <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® F_� Jeff Hudak <br />❑ Mary Wisniewski <br />