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CITY OfSOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM KXVVBE-1.0 <br />� ^` <br />K88E8WBEP4RT|C|PAT|ON <br />1865�» <br />I nis completed torm should be supplied with Bids that pertain to City of South Bend Public Works <br />|tiathe bidde�s sole respunoibiUtybuvorUwhether woman ects <br />of aK8in MBE/MBE' participation. <br />It <br />owned business. — <br />Project Number: 120-036 Project Name: WWTP Masonry Improvements Gallery Buildings 1-4 <br />Slatile Roofing and Sheet Metal Co., INC. Total Bid Amount: $420,218.00 MBEANBE Goal: <br />Name & Address of MBE/WB'E <br />Primary Contact Person <br />(Name[Telephone) <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />Dollar Amount of <br />MBEIWBE Component <br />Percentage <br />of Total <br />Submitted by: Gerald LOOg8rot-President <br />Print Name <br />Signature <br />Verskm4/2/2O19 Contractor's Bid for Public Works 9 <br />10/12/2020 <br />Date <br />