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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br />ANTICIPATED DBE PARTICIPATION STATEMENT <br />27s03aii <br />EQUAL OPPORTUNITY OFFICE <br />0XI1 <br />Page 2 0( d <br />1. FINANCIAL PROJECT NO. <br />13. SUBMfTTE�D},BY 14 .DATE 15. TITLE OF SU <br />2. FAP NO. <br />3. <br />CONTRACT NO, <br />4, COUNTY(IES) <br />S. DISTRICT <br />16. EMAIL ADDR OF SUBMITTER <br />17. <br />FAX NUMBER <br />18. PHONE NUMBER <br />6. PRIME CONTRACTOR NAME <br />THE FOLLOWING SECTIONS <br />ARE FOR FDOT USE <br />7. FEID NUMBER <br />19 .PROCESSED BY 20, DATE TO EO OFFICE <br />21. LETTING DATE <br />vZf vim' <br />22. EXECUTED DATE <br />23, PRECON CONF DATE <br />DIST <br />8. CONTRACT DO LAR AMOUNT <br />9. REVISION? IF YES, REVISION NUMBER: <br />10. IS THE PRIME CONTRACTOR A FLORIDA <br />CERTIFIED "DBE"7 (DISADVANTAGED <br />BUSINESS ENTERPRISE) <br />IJ2/N0 <br />❑ YES <br />11. IS THE WORK OF THIS CONTRACT <br />CONSTRUCTION ElOR MAINTENANCE R7/ <br />12, ANTICIPATED DBE SUBCONTRACTS: <br />EO <br />25 .INCLUDED IN DBE PARTICIPATION REPORT OF W911 <br />DBE SUBCONTRACTOR or SUPPLIER <br />TYPE OF <br />WORK/SPECIALTY <br />OFC <br />DOLLAR AMOUNT <br />PERCENT OF <br />CONTRACT <br />DOLLARS <br />A <br />B <br />C <br />D <br />E <br />12FTOTAL DOLLARS TO <br />DBE'S <br />12G TOTAL PERCENT <br />OF CONTRACT <br />$0.00 <br />0.00% <br />470-2 <br />BMIT(�TER <br />Wtf7V�lL �,'S " It hL, <br />n l� <br />TVze-e' O�e.VL <br />16. EMAIL ADDR OF SUBMITTER <br />17. <br />FAX NUMBER <br />18. 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 THE <br />CONTRACTUAL TERMS. THIS FORM MUST BE SUBMITTED AT THE PRE CONSTRUCTION OR PRE WORK CONFERENCE. FDOT STAFF <br />FORWARDS THE FORM TO THE EQUAL OPPORTUNITY OFFICE. <br />THE FOLLOWING SECTIONS <br />ARE FOR FDOT USE <br />19 .PROCESSED BY 20, DATE TO EO OFFICE <br />21. LETTING DATE <br />22. EXECUTED DATE <br />23, PRECON CONF DATE <br />DIST <br />24 .SUBMITTED TO EO <br />BY <br />En FAX ❑ EMAIL <br />❑ SHARED FOLDER <br />EO <br />25 .INCLUDED IN DBE PARTICIPATION REPORT OF W911 <br />OFC <br />470-2 <br />