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CITY OF SOUTH BEND+a <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <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 orwoman business meets the qualifications of a Minority or Women's <br />owned business. <br />Project Number: 119-078 <br />Pro)ect�Name <br />kin Struucture Patt Renj <br />Main8 Crrmoar�_.ovql.. <br />Bidder: <br />_ <br />Total Bid t <br />_ <br />MBE/VVBE Goal <br />�alv <br />Ww <br />Page <br />o <br />Name &Address of MBEIWBE <br />�_... <br />mary Contact <br />�Pr'e <br />(Name(felephone)on <br />ry <br />Scope of Performed <br />(Attach sc pe/schedule�if you bn need additional space) <br />Amount <br />MBE/WBE Comp nfent <br />odDollar e m <br />QnA,C-Q. <br />. <br />6ev <br />^^^X <br />Sar+a� lGS z .ems �Ass� �� <br />e <br />00 <br />tPdofit <br />_ <br />`1 �CvEe� <br />�'�_ k <br />c e um .j� cY c2 c'I c�`� <br />._._a <br />Submitted by: lt, <br />�d� ^ ����� <br />t q <br />Print Name.. <br />.. _ <br />alit�iu�re <br />. Date _— ... _... <br />...,, <br />Version 4/2/2019 Contractor's Bid for Public Works - 8 <br />