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t <br /> City �#Decatur, Illinois RETURN WITH Bid FOR EACH MBE <br /> ' tY SUBGOiyTRACTOR OR SUPPLIER <br /> #1 Gary K. Anderson Plaza <br /> Decatur, 1L 62523-1196 Minority Business Enterprise (MBE) <br /> Information Farm <br /> - - o�__ <br /> pate: Protect Title <br /> 1 r vim } ." <br /> t _ _ � �, <br /> -: Total Contract Value: �, S(�.� Project Number: av"r CU <br /> Section is Minority Business Enterprise(MBE)information <br /> Address. —-� <br /> v, <br /> Phone =� r r 1las <br /> Contact Person: <br /> Email: <br /> ' Section II: l:lescri tion of Services or Materials to be Provided ,.. .-------„ <br /> Estimated% of <br /> Description of Scope of Services Agreed Upon Estimated Amount Total Contract <br /> ' an submitted with the bid ro osal far each MBE. All MBEs intended for use on this <br /> This form must be completed d <br /> project shall have an MBE Information Form signed by the prime contractor and MBE. if for whatever reason the Prime <br /> Contractor changes or adds an MBE, a Notification of Change in Participation Form and MBE Information Form with the <br /> r necessary support documentation must be submitted and approved. <br /> The undersigned certifies that the information included herein is true and correct and the MBE subcontractor or material supplier <br /> has agreed to the scope of services described. The undersigned further certifies that this form is not a Contract between the <br /> City Prime Contractor or Subcontractor/Material Sapplie_ <br /> Prime C ntractor Si nature Print <br /> �. _.. - <br /> Title nate <br /> J)g Z' Z <br /> ' <br /> Minority Business Enterprise Signature Print <br /> .... _ <br /> tie <br /> _.,�_ - ate <br /> Ti <br /> 1 <br />