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City of Decatur, Illinois RETURN WITH BID FOR EACH MBE <br /> ! *) 1 #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: tr�� z�jL Project Title: 2 P�- f Lo L���c <br /> Total Contract Value: 4 1, 17-0e S/2 -f I Project Number: 2-01'.(1-2.5 <br /> Section I: Minority Business Enterprise(MBE)Information 7t'ap- <br /> ' Name: xIZcw�:ceZ ��:,`eC�:��eo\ �jz�'�:��5 LL, <br /> }C e3 L- COWVAsv'111L r j�L 6Z23y <br /> Address: )rl <br /> \ T <br /> Phone: <br /> ' Contact Person: <br /> Email: }C Sat�i\� ��h�;reZc�;c�rS r,�c�, , La'-' <br /> Section II: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated % of <br /> Total Contract <br /> r o z�3,aS <br /> �j <br /> laa tvorb• CoAccLFc_ C�-Irb vIJ ( 1r('er 6,14) t 2L;`i 29.I S <br /> r xGlue�eS �aw;�� r—u I`ro,Fc,C C�k-r.G <br /> This form must be completed and submitted with the bid proposal for each MBE. All MBEs intended for use on this <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 /> necessary support documentation must be submitted and approved. <br /> ' The undersigned certifies that the information included herdin 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 /> ' <br /> City, Prime Contractor or Subcontractor/Material Supplier. <br /> Prime Contractor Signature Print <br /> Q , ;' ( — —6?%6 IV, T <br /> Title 11Date <br /> 2 - 2 <br /> Minority Business Enterprise Signature Print <br /> Title Date <br /> x <br /> h-b.-�A <br /> 1 <br />