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275-021-13 EQUAL OPPORTUNITY 01/07 State of Florida Department of Transportation EEO Officer Notification This form is used by contractors to communicate the appointment of an EEO Officer and to provide EEO Officer Contact data The form is also used to update that information in the event of new appointees, name changes or contact data changes. Refer to the EEO Construction Contract Compliance Workbook and the FDOT contract for compliance program requirements and instructions. The contractor mails original of the completed form to FDOT Equal Opportunity Office 605 Suwannee Street-MS 65 Tallahassee, FI 32399-0450 A copy of the form is returned to the contractor upon completion of processing by FDOT General: Complete all boxes each time this form is submitted Section 1: Proiect Identification Box 1 Contractor Name — The name of the contractor Box 2 FEID No. — The contractor's Federal Identification Number Box 3 - Home Office Mailing Address (Street) — The contractor's home office street address; if the business' home office is outside of Florida, indicate the address of the Florida Home Office. Box 4- Home Office Mailing Address (City, State, Zip) — The contractor's home office city, state and zip code; if-the business' home office is outside of Florida, indicate the address of the Florida Home Office. Box 5 Main Phone No. — Area code and phone number contractor's main business phone Box 6 Fax Number No. — Area code and phone number contractor's main fax Box 7 What is Being Changed? — Mark 'Yes' or 'No" to indicate if this is the company's initial submission of EEO Officer information; If a new person has been appointed as EEO Officer, If the appointee of record had a name change, and if the appointee's contact data is being updated. Section 2: EEO Officer Identification Box 8 Name of EEO Officer— First name, middle initial and last name of EEO Officer Box 9 EEO Officer's Working Title — Job title if the EEO Officer has other duties (e.g. Treasurer, Manager of Contract Services, etc) Box 10 Work Address of EEO Officer (Street) —Address of EEO Officer's office Box 11 Work Address of EEO Officer (City, State, Zip) —Address of EEO Officer's office Box 12 EEO Officer Phone Number— Area code and phone number for EEO Officer Box 13 EEO Officer Fax Number— Area code and fax number for EEO Officer Box 14 EEO Officer email address — EEO Officer Email address Section 3: Signature of Corporate Official Box 15 Appointing Official's Signature — Signature of Company Official responsible for EEO Officer Appointment Box 16 Date (Mo/Day/Year) — Date appointing official signs this Notification form Box 17 Official's Name (printed) — Printed first name and last name of person signing Box 15 Box 18 Official's Title (printed) — Printed title of person signing Box 15 (e.g. President, CEO, etc) Section 4: Processing of Notification This section is completed by FDOT Box 19 Processed by — First and last name of person processing the Notification Box 20 Date Processed — Date processing is completed SAMPLE FORM FOR EEO COMPLIANCE/DATA COLLECTION 1V(1'TF• T'hic fnrm is cnhiPrf fn rhanap nr mndifirafinn