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City of Decatur, Illinois RETURN WITH BID FOR EACH MBE <br /> #1 Gary K. Anderson Plaza I SUBCONTRACTOR OR SUPPLIER <br /> Decatur, IL 62523-1196 Minority Business Enterprise (MBE) <br /> Information Form <br /> Date: 11/15/23 Project Title: Oakland and Grand Sewer Separation Project—Fairview Park <br /> Total Contract Value: Project Number: 2021-01 <br /> Section I: Minority Business Enterprise (MBE)Information <br /> ' Name: Agile Supply Company <br /> Address: 706 West Bradley Ave <br /> i ' Urbana, IL 61801 <br /> Phone: 217-729-2686 <br /> Contact Person: Bryan Banks <br /> Email: bryan.banks(a)_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 /> Sewer Structure Material $70,182.00 12.5% <br /> I <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 /> Prime Contractor Signature Print <br /> Justin Weidner <br /> Title Date <br /> Vice President 11/15/23 <br /> ' <br /> Minority Business Enterprise Signature Print <br /> Bryan Banks <br /> Title Date <br /> CEO 11-15-2023 <br /> ' 26 <br />