Laserfiche WebLink
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 2T"Xi-li <br /> ANTICIPATED DBE PARTICIPATION STATEMENT EQUAL OPPORTUNITY OFFICE <br /> a+n+ <br /> pagEL 3 of 9 <br /> 1.FINANCIAL PROJECT N0, 2. FAP NO. 3. CONTRACT NO. 4.COUNTY(IES) 5.DISTRICT <br /> G.PRIME CONTRACTOR NAME T.FEID NUMBER <br /> B. CONTRACT DO AR AMOUNT 0. REVISION? IF YES,REVISION NUMBER. I <br /> 10. IS THE PRIME CONTRACTOR A FLORIDA 11. IS THE WORK OF THIS CONTRACT <br /> CERTIFIED"OBE"?(DISADVANTAGED ® NO CONSTRUCTION®OR MAINTENANCE❑7 <br /> BUSINESS ENTERPRISE) ❑ YES <br /> 12.ANTICIPATED DBE SUBCONTRACTS: <br /> PERCENT OF <br /> DBE SUBCONTRACTOR or SUPPLIER TYPE OF WORKfSPEC1ALTY DOLLAR AMOUNT CONTRACT I. <br /> DOLLARS j <br /> A <br /> i <br /> B i <br /> I <br /> c ! I <br /> D i <br /> E <br /> 12F TOTAL DOLLARS TO 120 TOTAL PERCENT - <br /> DBE'S OFCONTRACT <br /> @@ I <br /> 13.SUBMITTED BY 14.DATE 15.TITLE OF SUBMITTER <br /> iG.EMAJLADDROA OF SUBMITTER 17.FAX NUMBER 18.PHONE NUMBER <br /> VYl.�sc..�C',C.p(vl�k.5�'. ►t'1�-�' 0c:1 <br /> NOTE:THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION IN ALL STATE AND FEDERALLY I <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 FDO'r USE <br /> 19.PROCESSED BY 20.DATE TO EO OFFICE 21.LETTING DATE22 EXECUTED DATE 23.PRECON CQNF DATE <br /> DIST <br /> 24.SUBNITTEDT0E0 ❑ PAX ❑ EMAIL <br /> BY I ❑ SHARED FOLDER <br /> Ep I 25.INCLUDED IN DBE PARTICIPATION REPORTOF MIDIY <br /> OFC <br /> _0D470-3 <br />