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CITY OF SOUTH BEND <br />"nrurxrrr�� <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />` <br />DEVELOPMENT PROGRAM <br />l <br />FORM MWBE-1.0 <br />MBEfWBE 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 />Projecte Cument Project, <br />Number: 118-0138 Project Name: Privet Lan Culvert Replace _ , ��.W._._....m............_. <br />Bidder: Selma Co traction Co. �_ Total Bid Amount: �$302m, 767.50 MBE/WBE Goal: 7.1 % <br />Inc. Page-1—of 1 _. <br />.............. Y .--....._ - P <br />Primary Contact Person Scope of Work to be Performed � Dollar Amount of Percentage <br />Name &Address of MBFJWBE ry p of Total <br />(Name/Telephone) (Attach scope/schedule if you need additional space) MBFJWBE Com onent <br />dTLOPasal <br />a 81 <br />to Barricing._ _.. ..�.. <br />PO Box 3751 James <br />South Bend, IN Michalski Traffic Control $1,000.00 1 <br />574-287-207 <br />Submitted by: Robert Kuhns, PrOectm Bra i eer Q1 9 <br />Print Name Signature Date <br />Version 10/17/2017 Contractors Bid for Public Works - 9 <br />