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,4,1i . H .. t r, <br />d> <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM' <br />FORM MWBE-1.0 <br />MWBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE/IWBE <br />participation. It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the <br />qualifications of a Minority or Women's owned business. <br />Project Number: 120-019 _ Project Name: 1201 Western Ave,,Sidewalk Vault Repair <br />Bidder: V,'Cloq' <br />? MWBE Coal: <br />y1al Bid Amount: <br />Pageof <br />Name & Address of MVVBE <br />Printary Contact Person <br />(Naeffelephorre) <br />rn <br />Scope of Work to he Performed <br />(Attach scope/schedule if you nadditional space� <br />Doflar Amount of MVVBE <br />C, <br />Component <br />cent <br />Percentage <br />of Total <br />117 <br />Submitted by: I <br />Pr nt Name Si <br />ature <br />Date <br />Versicn 2/1412020 Page - 12 PUblic Works Q1,10fe <br />