Laserfiche WebLink
STATF OF FLORIDA DEPAR I MEN I Ur I K/\NJ UK I N 1 IVN <br /> NOTIFICATION TO FDOT OF EEO OFFICER tEQUAL OPPORTUNITY <br /> — 4 ef <br /> iAt k �L° <br /> Mail signed original to : <br /> FDOT Equal Opportunity Office , 605 Suwannee Street- MS 65 , Tallahassee , FI 32399- 0450 <br /> Section 1 : COMPANY IDENTIFICATION <br /> 1 . Con/t�raactoor� Name : 2 . . FEID No . : <br /> 3_H me Office Mailing Address : ( str t�_ 4. Home Office Mailing Address : (city, State, Zip)) <br /> , ate_ L_71a <br /> 5 . Main Phone Number: 6 . Fax Number: <br /> 2 - I . 5 ' 2 - — - --- '21 - a 0 4 <br /> 7 . What is being Initial, EEO Officer Notice to FDOT New Person A ointed Appointee Chan ed Name Contact Data Chan ed <br /> Changed ? Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> ❑ Yes ❑ No <br /> Section 2 : EEO OFFICER IDENTIFICATION <br /> 8 , NL� /m� e. o'ff EEO Officer : ( first name, middle initial, last name) 9. EEO Officer's Working <br /> Title : <br /> __I-�d.�L1 1 �� iri � —1..1 _ l C�.� r" 1" C� z• !J - <br /> 10 . Work Address of EEO Officer: (Street) 11 . Work Address of EEO Officer: ( city , state , zip) <br /> 12 . EEO Officer Phone Number: 13 . EEO Officer Fax Number: <br /> 14 , EEO Officer email address : —ter <br /> Section 3 : SIGNATURE OF CORPORATE OFFICIAL <br /> Ll <br /> As required in the Equal Employment Opportunity Special Provisions included in Federallaunded <br /> Highway Construction Contracts and as required in the Equal Employment Oppprtun <br /> Requirements included in all State funded highway construction contracts , this official notica=of EEO <br /> Officer appointment ( and /or update ) is made to the Florida Department of Transportation and -the <br /> U . S . Federal Highway Administration ( FHWA) . I understand that additional Information regarding the <br /> EEO Officer , the EEO Policy and other aspects of the construction contract compliance program may <br /> be found in the EEO Construction Contract Compliance Workbook . <br /> 15 . Appointing Official 's Signature : 16. Date : (MolDa01 <br /> y/yr.) <br /> 17 . Of)fclal 's Name : rinted <br /> (P ) 18 . Official 's Title : (printed) <br /> ( This Section For FDOT Use ) Section 4 : Processing of Notification <br /> ii <br /> 19 . Proces d y : ( First and Last e) 20 . Date Processed : ( mo/day/yr) <br /> -C>1T z I <br /> DISTRIBUTIO Ongi "tto Central EO Office ;C-nny <br /> : Mailed to Contractor <br /> UPDATE ACTION : Input In EOR System <br /> FLORIDA DEPARTMENT OF TRANSPORTA1I0� <br /> EQU kLOPP - TUNI" OFFICE <br /> APPROVED : ^' <br /> DISAPPROVED : ---- <br /> [GATE : 2 i i <br />