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RETURN WITH BID FOR EACH MBE <br /> City of Decatur, Illinois SUBCONTRACTOR OR SUPPLIER <br /> #1 Gary K. Anderson Plaza <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> ' Date: 10/26/2023 Project Title: 2023 STORM DRAINAGE IMPROVEMENT PROJECT <br /> Total Contract Value: Project Number: 2023-30 <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: 217-729-2686 <br /> Contact Person: Bryan Banks <br /> Email: Bryan.Ban ks(c_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 /> ' Total Contract <br /> Supply of storm piping and misc. valves/fittings $52,435.85 31.1% <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 /> ' <br /> City, Prime Contractor or Subcontractor/Material Supplier. <br /> Pri e_:Contractor Signature Print <br /> L( s� < <br /> Tit a Date <br /> e- �r�S <br /> Minority Business Enterprise Signature Print <br /> Bryan Banks <br /> T e Date <br /> ' CEO 10-26-2023 <br /> 29 <br />