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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275-021-13 ' <br /> NOTIFICATION TO FDOT OF EEO OFFICER EQUAL OPPORTUNITY. <br /> o1io7 <br /> Mail signed original to- <br /> FDOT Equal Opportunity Office , 605 Suwannee Street-MS 65, Tallahassee, FI 32399-0450 <br /> Section 1: COMPANY IDENTIFICATION <br /> 1. Contractor Name: 2.. FEID No.- <br /> 3. Home Office Mailing Address:(street) 4. Home Office Mailing Address:(city,State,Zip)) <br /> 5. Main Phone Number 6. Fax Number: <br /> 7. What is being I Initial EEO Officer Notice to FDOT I New Person Appointed Appointee Changed Name I Contact Data Changed <br /> Changed? ❑ Yes ❑ No I ❑ Yes LINO ❑ Yes ❑ No I ❑ Yes ❑ No <br /> Section 2: EEO OFFICER IDENTIFICATION <br /> 8. Name of EEO Officer:(first name, middle initial,last name) 9 EEO Officer's Working Title: <br /> 10. Work Address of EEO Officer: (Street) 11. Work Address of EEO Officer- (city,state,zip) <br /> 12.EEO Officer Phone Number- 13. EEO Officer Fax Number: <br /> 14 EEO Officer email address: <br /> Section 3: SIGNATURE OF CORPORATE OFFICIAL <br /> As required in the Equal Employment Opportunity Special Provisions included in Federally Funded <br /> Highway Construction Contracts and as required in the Equal Employment Opportunity <br /> Requirements included in all State funded highway construction contracts, this official notice of EEO <br /> Officer appointment (and/or update) is made to the Florida Department of Transportation and the <br /> U.S. Federal Highway Administration (FHWA). I understand that additional Information regarding the <br /> EEO Officer, the EEO Policy and other aspects of the construction contract compliance program may <br /> be found in the EEO Construction Contract Compliance Workbook. <br /> 15. Appointing Official's Signature: 16.Date:(Mo/Day/Yr.) <br /> 17. Official's Name:(printed) 18. Official's Title:(printed) <br /> (This Section For FDOT Use) Section 4: Processing of Notification <br /> 19 Processed by(First and Last Name) 20 Date Processed:(mo/day/yr) <br /> DISTRIBUTION: Original to FOOT Central EO Office Files;Copy Mailed to Contractor <br /> UPDATE ACTION: Input In EOR System <br /> SAMPLE FORM FOR EEO COMPLIANCE/DATA <br /> COLLECTION <br /> NOTE: This form is subject to change or modification <br />