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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275-030-11A <br /> ANTICIPATED DBE PARTICIPATION STATEMENT EQUAL OPPORTUNITY OFFICE <br /> 02/08 <br /> 1 . FINANCIAL PROJECT NO . 2 . FAP NO . 3 . CONTRACT NO . 4, COUNTY( IES ) 5, DISTRICT <br /> 6 . PRIME CONTRACTOR NAME 7 . FEID NUMBER <br /> 8 . CONTRACT DOLLAR AMOUNT 9 . REVISION ? IF YES , REVISION NUMBER : <br /> 10 . IS THE PRIME CONTRACTOR A FLORIDA 11 , IS THE WORK OF THIS CONTRACT <br /> CERTIFIED " DBE" ? ( DISADVANTAGED ❑ NO CONSTRUCTION El OR MAINTENANCE El ? <br /> BUSINESS ENTERPRISE) ❑ YES <br /> 12 . ANTICIPATED DBE SUBCONTRACTS : <br /> PERCENT OF <br /> DBE SUBCONTRACTOR or SUPPLIERTYPE OF WORK/SPECIALTY DOLLAR AMOUNT CONTRACT <br /> DOLLARS <br /> A <br /> B <br /> PDC <br /> E <br /> F 11A TOTAL DOLLARS TO 11B TOTAL PERCENT OF <br /> DBE'S CONTRACT <br /> $ 0 . 00 0 . 00 % <br /> 13 , SUBMITTED BY 12 . DATE 13 . TITLE OF SUBMITTER <br /> 14. EMAIL ADDRESS OF SUBMITTER 15. FAX NUMBER 16 , PHONE NUMBER <br /> NOTE : THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION IN ALL STATE AND FEDERALLY <br /> FUNDED FDOT CONTRACTS . THE ANTICIPATED DBE AMOUNT IS VOLUNTARY AND WILL NOT BECOME A PART OF <br /> THE <br /> CONTRACTUAL TERMS . THIS FORM MUST BE SUBMITTED AT THE PRE CONSTRUCTION OR PRE WORK CONFERENCE, FOOT STAFF <br /> FORWARDS THE FORM TO THE EQUAL OPPORTUNITY OFFICE. <br /> TIME FOLLOWING SECTIONS ARE FOR FDOT USE <br /> 17 .PROCESSED BY 18. DATE TO EO OFFICE 19. LETTING DATE 20. EXECUTED DATE 21 . PRECON CONF DATE <br /> DIS <br /> T 22 .SUBMITTED TO EO BY ❑ FAX ❑ EMAIL <br /> ❑ SHARED FOLDER <br /> EO 23 .INCLUDED IN DBE PARTICIPATION REPORT OF MIDIY <br /> OFC <br />