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CITY OF SOUTH BEND )A1r"°r <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY "10 1' <br />DEVELOPMENT PROGRAM,; <br />FORM MWBE-1.0 <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: 119-004 Project Name 01 Curb and Sldie atk Construction <br />Bidder: Total Bid Amount. ,2, 5- MBEIWBE Goal. 0 <br />Page�—of� <br />.......................... ............ --.... _, ...................... ..... _-------- <br />.... <br />Primary Contact Person Scope of Work to be Performed Dollar Amount of Percentage <br />Name 8 Address of MBENVBE (Name/Telephone)of Total <br />p y pace) MBFaIN.. Component Bid/Proposal <br />---- _ �.„........ <br />Hach scope/schedule a schedule i you need additional s LL"` v _ _ _ <br />18,4S 6- �I..,cr�st s 7,�- �3y-ia�� � r�.t,�A-- J <br />Iq-,- J . Zn <br />r�L�1 d <br />Submitted by: _ s r, <br />(+ 4e N.7 -- ------ <br />Print Name SIg,nat Date <br />Version 10/17/2017 Contractors Bid for Public Works - 4 <br />