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CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY{ <br />DEVELOPMENT PROGRAM J <br />FORM MWBE-1.0 <br />MBEIWBE PARTICIPATIONw <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 orwoman business meets the qualifications of a Minority or Women's <br />owned business. <br />Project Number: 119-004 /� Project Name: 2019 Curb and Sidewalk Construction <br />/' (_ 6i1G�G7�ill/GLS Total Bid Amount. MBENVBE Goal: <br />Bidder: P# C��ar,rt . <br />Page of <br />Name &Address of MBE/WBE <br />Primary Contact Person <br />(Name(rele hone <br />p ) <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />Dollar Amount of <br />MBE/WBE Component <br />m <br />Percentage <br />of Total <br />Bid/Proposal <br />pre.&ih, , Coieed-r— <br />Y <br />A&MOVOs 1&4,-,n -611 <br />f <br />$trViGts <br />3Tli7s15- <br />.. . ....... <br />.......... ........ <br />s--7a <br />Submitted by: A r*ce 1- <br />... �-- -- -------... .. -...._ <br />Print Name ggtature Date <br />Version 10/17/2017 Contractors Bid for Public Works - 4 <br />