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CITY OF SOUTH SEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-1.0 <br />MBEIWBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBEIMBE <br />participation. It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a <br />Minority or Women's owned business. <br />Project Number: <br />Bidder: <br />116-012 <br />Project Name: <br />Fire Station #9 <br />Gibson-LeNvis, LLC Total Bid Amount: <br />MBEANBE Goal: <br />Page of <br />Name & Address of MBEMBE <br />Primary Contact Person <br />(Namerrelephone) <br />Scope of Work to be Performed <br />tAllach scope/schedule if you need additional space) <br />Dollar Amount of <br />MBENWE Component <br />Percentage <br />of Total <br />Submitted by: Robert A. Lingenfelter, President 2/27/18 <br />Print Name Signature Date <br />Version 10117/2017 Contractor's Bid for Public Works - 11 <br />