Laserfiche WebLink
1 <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br />ANTICIPATED DBE PARTICIPATION STATEMENT <br />275-030-11 <br />EQUAL OPPORTUNITY OFFICE <br />03/11 <br />Page 2 of 8 <br />1 FINANCIAL PROJECT NO. <br />2. FAP NO. <br />3. CONTRACT NO. <br />4. COUNTY(IES) <br />5. DISTRICT <br />-' % , 5I - <br />`2.31,A0 -Z -S' -o1 <br />wiu.d $z <br />Inchletuc- <br />il <br />6. PRIME CONTRACTOR NAME <br />7. FEID NUMBER <br />Tm0 ,o � C ' ± ci it <br />6s- -0 z- li2.42.. <br />8. CONTRACT DOLLAR AMOUNT <br />1291 ZOO :3-2 <br />9. REVISION? <br />IF YES, REVISION <br />NUMBER: <br />22. EXECUTED DATE <br />23. PRECON CONF DATE <br />10. IS THE PRIME CONTRACTOR A FLORIDA <br />CERTIFIED "DBE"? (DISADVANTAGED <br />BUSINESS ENTERPRISE) <br />YES <br />11. IS THE WORK <br />CONSTRUCTION <br />OF THIS CONTRACT <br />- <br />1? OR MAINTENANCE ■? <br />❑ FAX ❑ EMAIL <br />❑ SHARED FOLDER <br />12. ANTICIPATED DBE SUBCONTRACTS: <br />DBE SUBCONTRACTOR or SUPPLIER <br />TYPE OF WORK/SPECIALTY <br />DOLLAR AMOUNT <br />PERCENT OF <br />CONTRACT <br />DOLLARS <br />A <br />ii. <br />' <br />v <br />-----.. ___ . <br />B <br />C <br />D <br />E <br />12F TOTAL DOLLARS TO <br />DBE'S <br />12G TOTAL PERCENT <br />OF CONTRACT <br />$0.00 <br />0.00% <br />13. SUBMITTED BY <br />14 .DATE <br />15. TITLE OF SUBMITTER <br />16. EMAIL RESS OF SUBMITTER <br />17. 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 ARE FOR FDOT USE <br />DIST <br />19 .PROCESSED BY <br />20. DATE TO EO OFFICE <br />21. LETTING DATE <br />22. EXECUTED DATE <br />23. PRECON CONF DATE <br />- <br />24.SUBMITTED TOEO <br />8Y <br />❑ FAX ❑ EMAIL <br />❑ SHARED FOLDER <br />EO <br />OFC <br />25 .INCLUDED IN DBE PARTICIPATION REPORT OF (M/DN) <br />T-- <br />-----.. ___ . <br />470-2 <br />