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CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-1.0 <br />MBEIWBE PARTICIPATION <br />i ms comptereo corm snoufo oe supplteo wian was anax pertasn to ally Or zioutri tsenaa Pura is vitorss vrolects involving rdbt:imut: 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: 118-097 Project Name: Ewing Avenue and Fellows Street Intersection Traffic Signal <br />Bidder: Michiana Contract!M, Inc Total Bid Amount: 231,373.00 MBENVBE Goal: 0% <br />Page 1 of 1 <br />Name &Address of MBENVBE <br />Primary Contact Person <br />Scope of Work to be Performed <br />Dollar Amount of <br />Percentage <br />of Total <br />(Namerrelephone) <br />(Attach scope/schedule if you need additional space) <br />MBE/WBE Component <br />Bid/Proposal <br />Premium Concrete Services <br />Rob Becker <br />Concrete services <br />55,830.00 <br />24.1% <br />712 Richmond Street <br />Elkhart, IN 46516 <br />//AA,"--� <br />Submitted by: Scott Kirkpatrick, President 11/12/19 <br />Print Name Signature Date <br />Version 1/17/2019 Contractors Bid for Public Works - 9 <br />