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CITY OF SOUTH BEND" <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY x <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 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: 119-064 Project Name: 315 & 319 W. Jefferson Exterior Renovations <br />Bidder: Herrman & Goetz, Inc. Total Bid Amount: $82,555.00 MBEANBEGoal: <br />Page of <br />...ww.W....... w.w......................... <br />Primary Contact Person Scope of Work to be Performed Dollar Amount of Percentage <br />Name &Address of MBEIWBE (Namelrelephone) (Attach scope/schedule if you need additional space) MBE/WBE Component of Total <br />Bid/Pro osal <br />e are using our own work force <br />......... .................. _._. <br />......... _...... .............. . <br />Submitted by: Larry Cripe.. ..._.� L_�_ 2QL _................ <br />Print Name 4S,ature D� <br />Version 4/2/2019 Contractor's Bid for Public Works - 9 <br />