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CITY OF SOUTH BEND 41iii <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-11.0 <br />MBEIWBE PARTICIPATION <br />IZE5�1 — <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBEIMBE <br />participation. It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a <br />Minority or Women's owned business. <br />Project Number: 119-049 Project Name: VESTED INTEREST BUILDING ROOF REPAIR <br />Bidder:Slatile RoofingArA.Sheet Metal CO., IN&al Bid Amount: MBEANBE Goal: <br />_$�19,812,00 <br />Name & Address of MBEWBE <br />• <br />retracting out any <br />Primary Contact Person <br />Scope of MA to be Pc rform ud <br />(Namerra�ophone)(Attach tcopoIschedulo if you need additional space) <br />Submitted by: QgmWJp_nqerot - r -Egsidgnt <br />— <br />Print Name <br />Version 412/2019 Contractor's Bid for Public Works - 8 <br />Page of <br />Dollar Amount of I Total <br />MBEMBE Component <br />9/9/19 <br />Date <br />