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CITY OF SOUTH BEND Jt Suvra eEM <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-2.1 m <br />MBEIWBE CONTACTED 1965 t' <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects <br />requiring contacted MBEIWBE to obtain Good Faith Efforts. It is the bidder's sole responsibility to verify <br />whether any listed minority or woman business meets the qualifications of a Minority or Women's owned <br />business. <br />PAGE OF <br />Project Number: 166-066 MBEANBE Participation Goal <br />Project Name: Fire Station #4 <br />Bidder: Q Ziolkowski construction, Inc. <br />By: 4wz,? 7 Bill Favors President December 13 2016 <br />/(Signature) (Title) (Date) <br />MBEANBE Firm <br />Owner or Contact at MBEANBE Firm <br />Telephone: Fax: Email: <br />TYPE OF WORK SOLICITED FOR THIS PROJECT: <br />RESULTS OF CONTACT WITH THE MBEANBE FIRM: <br />MBE/BE Firm <br />Owner or Contact at MBE/WBE Firm <br />Telephone: Fax Email: <br />TYPE OF WORK SOLICITED FOR THIS PROJECT: <br />RESULTS OF CONTACT WITH THE MBEANBE FIRM: <br />Version 10/18/2016 Contractor's Bid for Public Works - 12 <br />