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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275-030-11 <br /> ANTICIPATED DRE PARTICIPATION STAEQUAL <br /> 03191 <br /> Page 2 of 8 <br /> 1.FINANCIAL PROJECT NO. 2. FAP NO. 3. CONTRACT NO. 4.COUNTY IES 5. DISTRICT <br /> Z01,1110 �2 <br /> 6.PRIME CONTMCTTOR NAME 7.FEID NUMBER <br /> of 1._t !►'1 �j C) <br /> B. CONTRACT DOLLAR AMOUNT 9. REVISION? IF YES,REVISION NUMBER: <br /> 9 2_0c :,S <br /> 10. IS THE PRIME CONTRACTOR A FLORIDA 11. IS THE WORK OF THIS CONTRACT <br /> CERTIFIED"DBE"?(DISADVANTAGED CONSTRUCTION®OR MAINTENANCE E17 <br /> BUSINESS ENTERPRISE) ' a YES <br /> 12.ANTICIPATED DBE SUBCONTRACTS: <br /> PERCENT OF <br /> DBE SUBCONTRACTOR or SUPPLIER TYPE OF WORKISPECIALTY DOLLAR AMOUNT CONTRACT <br /> DOLLARS <br /> A a <br /> B <br /> v <br /> C <br /> D <br /> 12F TOTAL DOLLARS TO 12G TOTAL PERCENT <br /> DBE'S OF CONTRACT <br /> $0.00 0.00% <br /> 13.SUBMITTED BY 14.DATE 15.TITLE OF SUBMITTER <br /> 16.EMAIL ADbRESS OF SUBMITTER 17.FAX NUMBER Q 18.PHONE NUMBER <br /> 1- <br /> NOTE: THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION IN ALL STATE AND FEDERALLY <br /> WWI 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 /> 19.PROCESSED BY 20.DATE TO EO OFFICE 1 21.LETTING DATE 22-EXECUTED DATE 23.PRECON CONF DATE <br /> DIST <br /> 24.SUBMITTEDTOEO ® FAX ❑ EMAIL <br /> BY ❑ SHARED FOLDER <br /> EO 25.INCLUDED IN DBE PARTICIPATION REPORT OF MlD/Y <br /> OFC <br /> 470-2 <br />