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tip tf TF! <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />1'I:AI'F 'y <br />FORM MWBE-1.0 <br />MBE/WBE PARTICIPATION rens <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 />118-005A <br />Project Name: North Shore Drive Bank Stabilization <br />ECL- 4, .? Ic Total Bid Amount: <br />MBENVBE Goal: <br />Page I of 1 <br />Name & Address of MBENVBE <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 />MBENVBE Component <br />Percentage <br />of Total <br />Bid/Pro osal <br />C— 71 c �L <br />h)✓ <br />3I `7— 5 1j %y y' <br />�� <br />c2� r p Gil % 7- J JN <br />Submitted by: ��C1, <br />�r �1S�c�f <br />Print Name ' Sig`n`ature i' Date <br />Version 01/29/2020 Contractor's Bid for Public Works - 8 <br />