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RETURN WITH BID FOR EACH MBECity of Decatur, Illinois <br /> #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: Project Title: 2-,o?-I <br /> L <br /> Total Contract ValLie: Project Number: 7-ou-25 <br /> ......................... <br /> Section 1: Minority Business Enterprise (MBE)Information <br /> Name: -2 <br /> Address: <br /> Phone: <br /> Contact Person: A f M--41 C bic C S h-A —----- <br /> Email: <br /> Section [I: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated % of <br /> Total Contract <br /> V oc*-( Q too ,0 0 <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 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 Sup tier. <br /> Prime Contractor Signature Print <br /> Titt Date <br /> 240 2-1 <br /> . ........................ ...... <br /> Minority Business Enterprise Signature Print <br /> J�- �kffqc�f wo� 4v� <br /> T i t I e ti Date <br /> . LJ <br /> ......... <br /> OWO <br /> Ak, <br />