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r <br /> City of Decatur, Illinois RETURN WITH BID FOR EACH MBE <br /> #1 Gary K. Anderson Plaza <br /> SUBCONTRACTOR OR SUPPLIER <br /> ' Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> 1 Date: .- ' Z.Q Z Project Title: C•� L 1' 't O L- <br /> t� 1 -- <br /> Total Contract Value: . Project Number: (A-C\Z -r 2 per,(.-2,,5 <br /> Section 1: Minority Business Enterprise (MBE)Information <br /> 1 Name: x SjkAAES <br /> Address: X et <br /> Phone: ! l 1 =� •- <br /> 1 <br /> Contact Person: , <br /> r Email: V64, <br /> �. <br /> Section I1: Description of Services or Materials to be ovided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated % of <br /> 1 Total Contract <br /> 1 <br /> 1 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 /> rnecessary 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 /> 1 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 Supplier. <br /> Prime Contractor Signature Print �y <br /> Tx-7 tu <br /> T Date <br /> Minority Business Enterprise Signature Print <br /> 1 ")e- <br /> Title Date <br /> 'T <br />