Laserfiche WebLink
' Cit of Decatur Illinois RETURN WITH BID FOR EACH MBE <br /> Y s <br /> #1 Gary K. Anderson Plaza SUBCONTRACTOR®R SUPPLIER <br /> ' Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> 1 Date: �j f �' ' Project Title � siuli <br /> Total Contract Value: Project Number: j: 2.--6j-C <br /> Section I: Minority Business Enterprise (MBE)Information <br /> ' Name: ► jet C�k E <br /> Address: 05 11T <br /> `C Z, <br /> Phone: ' +�. �1 _ - <br /> r <br /> Contact Person: J1 } jCj <br /> Email: <br /> Section I1: 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 /> Prime Contractor Signature Print <br /> t f <br /> Title ^. ,_ Date <br /> Minority Business Ent rp ' e Signature Print <br /> _ y V td, , <br /> Title Date <br /> ' 26 <br />