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1 City of Decatur, Illinois RETURN WITH BID FOR EACH MBE <br /> #1 Gary K. Anderson Plaza I SUBCONTRACTOR DR SUPPLIES <br /> ' . > Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> ' lysate: _4_2- I Project Title: Old King's Orchard Garden <br /> Total Contract Value: ,�) Project Number: 202305 <br /> ' Section I: Minority Business Enterprise(MBE)Information <br /> Name: (:�), 'C--.. V-1 (�V,- � ( 1 ie ,...� <br /> 1 r <br /> Address: � o l__..e <br /> c,-JnLo Ll <br /> 1 Ck.l �VA y C6 m 2� <br /> Phone: <br /> 1 �- �� <br /> Contact Person: �.,. � <br /> Email: c,J <br /> ' Section il: Description of Services or Materials to be Provided <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 /> 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 /> ity, Prime Contractor or Subcontractor/Material Supplier. <br /> ' Prime Contractor Signature Print <br /> Title Date <br /> Vr ,A <br /> 1 Minority Business Enterprise Signature Print <br /> Title Date <br /> 1 �s <br />