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CITY OF SOUTH BEND <br />: c4souri�H j <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWSE-1.O <br />MBEIWBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBEIMBE participation. <br />It is the bidder's sole responsibility to verify whetherany listed minority orwoman business meets the qualifications of a Minority or Women's <br />owned business. <br />Project Number: 117-1ODR Project Name: Lafayette Building Exterior Renovation <br />Bidder: Total Bid Amount: MBEMlBE Goal: <br />Page of <br />Name & Address of M8ENY8E <br />Primary Contact Person <br />(Namefrelephone) <br />Scope of Work to be Performed <br />(Attach scope/schedule ![you need addiliona€ space) <br />not18rAmounl of <br />M85ANBE Component <br />Percentage <br />of Total <br />BidlPra osal <br />G�11,SURaI <br />�7tc u, <br />CA 0JP <br />_ <br />cc€�S1sTR�Gl��i1! <br />�J�J O r `' <br />Submitted by: I ��Ael <br />Print Name Signature Dat <br />Version 712012018 Cantractor's Bid for Public Works - s <br />