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f � City of Decatur, Illinois RETURN WITH BIDS OR EACH MBE <br /> #1 Gary K. Anderson Plaza SUBCONTRACTOR OR SUPPLIER <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> :Dapte. 4!20/2022 Project Title: 2022 Storm Drainage Improvements <br /> Toract Value: 277,010 Project Number: 2022-30 <br /> ' Section I: Minority Business Enterprise(MBE)Information <br /> Name: Agile Supply Company <br /> ' Address: 706 West Bradley Ave <br /> Urbana,IL 61801 <br /> ' Phone: 312-972-5551 <br /> Contact Person: Bryan Banks <br /> Email: bryan.banks@agilesupplycompany.com <br /> Section II: Description of Services or Materials to be Provided <br /> Description of Scope of Services Agreed Upon Estimated Amount Estimated %of <br /> Piping and Material supply Total Contract <br /> 27,701 10 <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 /> m ontractor Signature Print <br /> ' Title Date <br /> Minority Business Enter . a Signature Print <br /> Title <br /> Date <br /> C,-E jJ K`d,t9t� <br /> ' 27 <br />