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CITY OF SOUTH BEND <br />Primary Contact Person <br />(Name/Telephone) <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />ry <br />DEVELOPMENT PROGRAM <br />-' <br />FORM MWBE-1.0 <br />� <br />MBE/WBE 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 />Project Number: <br />Bidder: <br />116-127A <br />Project Name <br />R;ejI 6.. In <br />Sheridan Street and Sample Street Signal Improvements <br />Total Bid Amount: , �MBE/WBE Goal: 101 <br />Page_/of 1 <br />Name & Address of MBE/WBE <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 />MBE/WBE Component <br />Percentage <br />of Total <br />Bid/Proposal <br />Submitted by:v� <br />Print Name Signature <br />Version 4/2/2019 Contractor's Bid for Public Works - 10 <br />Date <br />