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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275030,11 <br /> EQUAL OPPORTUNITY OFFICE <br /> ANTICIPATED DBE PARTICIPATION STATEMENT 03111 <br /> Page 2 of 8 <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 /> a 0 ;Zw s o` <br /> 8. CONTRACT DOLLAk AMOUNT 9. REVISION? IF YES, REVISION NUMBER: <br /> 10. IS THE PRIME CONTRACTOR A FLORIDA 11 . IS THE WORK OF TH CONTRACT <br /> CERTIFIED "DBE"? (DISADVANTAGED �O CONSTRUCTION OR MAINTENANCE [17BUSINESS ENTERPRISE) ❑ YES <br /> 12, ANTICIPATED DBE SUBCONTRACTS : <br /> PERCENT OF <br /> DBE SUBCONTRACTOR or SUPPLIER TYPE OF WORWISPECIALTY DOLLAR AMOUNT CONTRACT <br /> DOLLARS <br /> A <br /> B <br /> C <br /> D <br /> E <br /> 12F TOTAL DOLLARS TO 120 TOTAL PERCENT <br /> DBE'S OF CONTRACT <br /> $0.00 0.00% <br /> 13. SUBMITTED BY 14 .DATE 15. TITLE OF SUBMITTER <br /> jn <br /> VV\ b S,R.._ cl ( Iz I z2 SLcQ <br /> 16. EMAIL ADDRESS OF SUBMITTER 17. FAX NUMBER 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 <br /> THE <br /> CONTRACTUAL TERMS. THIS FORM MUST BE •SU13MITTED AT THE PRE CONSTRUCTION OR PRE WORK CONFERENCE FDOT STAFF <br /> FORWARDS THE FORM TO THE EQUAL OPPORTUNITY OFFICE <br /> THE FOLLOWING SECTIONS ARE FOR FDOT USE <br /> 19 .PROCESSED BY 20, DATE TO EO OFFICE 21 . LETTING DATE 22 EXECUTED DATE 23. PRECON CONF DATE <br /> DIST <br /> 24 .SUBMITTED TO EO ❑ FAX ❑ EMAIL <br /> i <br /> BY ❑ SHARE ) FOLDER <br /> EO 25 .INCLUDED IN DBE PARTICIPATION REPORT OF (MIM) <br /> Ve <br /> pt <br /> 470 - 2 <br /> . x' 4 <br />