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City of Decatur, Illinois RETURN WITH BID FOR EACH MBE <br /> ( <br /> #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> : <br /> • Decatur, IL 62523-1196 Minority/ Business Enterprise (MBE) <br /> Information Form <br /> Date: _�_ Project Title: -r- <br /> Total Contract Value: t--� ���� Project Number: <br /> Section I: Minority.Business Enterprise(MBE)Information <br /> Name: i <br /> Address: ---_ �9. <br /> Phone: 91 CA _ 2-SS- 2, <br /> Contact Person: <br /> Email: <br /> Section If: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated %of <br /> Total Contract <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 Supplier. <br /> PdMg Contractor Signature Print <br /> 4 A 1E VJ- <br /> Ti Date <br /> Minority,4s,iqesjqEnteSignature Print <br /> Title Date <br /> 28 <br />