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",V" <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-11.0 Pl,�� <br />MBEIWBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE/MBE participation. <br />It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a Minority or Women's <br />owned business, <br />Project Number: 118-063 <br />Project Name: <br />Smail Drain <br />_Mag& Design and Repair <br />Bidder: Selge <br />Con_aU_(;ti_Q_n_QQ,j <br />TotalBidAmount: $ 657,576.35 <br />MBE/WBE Goal: <br />7.1% <br />........... <br />Inc. <br />Page 1 <br />of 1 <br />Name & Address of MBEMBE <br />Primary Contact Person <br />(Namerrelephone) <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />. ........ <br />Dollar Amount Of <br />IMBENVIBE Component <br />Percentage <br />of Total <br />i t e rrica ing <br />. <br />. . . ........... .... .......... . . <br />Pi ropasal <br />Box 3751 <br />James <br />0. Bend, IN 46628 <br />Michalski <br />Traffic Control <br />$ 5,255.00 <br />1% <br />574-287-2078 <br />Slusers Green Thurro <br />PO Box 33 <br />John <br />L09anSPOrt, IN 46947 <br />Seeding & Sod <br />$15,972.00 <br />2 to <br />..... . . ..... <br />57 .4=722=31-02- <br />Submitted by: <br />......... . . <br />. . ............... ... ........ <br />P--� <br />. ........... . . .... ......... <br />12/11/18 <br />Prkit Name Engineer <br />Signature <br />Date <br />Version 7/20/2018 Contractor's Bid for Public Works - 12 <br />