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STATE OF FLORIDADEPARTMENTOFTRANSPORTATION 2T6-030-11 i; <br /> ANTICIPATED DBE PARTICIPATION STATEMENT EQUAL OPPORTUNITY OFFIGE <br /> 03I11 , <br /> pager 3 of 9 <br /> la . <br /> 1.FINANCIAL PROJECT NO. 2, FAP NO, 3. CONTRACT NO. 4.COUNTY IES 5,DISTRICT <br /> S.PRIME CONTRACTOR NAME 7.FEID NUMBER <br /> B. CONTRACCTp DOLLAR AMOUNT 9. REVISION? IF YES,REVISION NUMBER: <br /> 4c !j I k r "�q <br /> 10. IS THE PRIME CONTRACTOR A FLORIDA 11. IS THE WORK OF THIS CONTRACT <br /> CERTIFIED"DBE"?(DISADVANTAGED �"NO CONSTRUCTION OR MAINTENANCE 07 <br /> BUSINESS ENTERPRISE) ❑ YES <br /> 12.ANTICIPATED DBE SUBCONTRACTS: <br /> PERCENT OF <br /> DBE SUBCONTRACTOR or SVPPLIER TYPE OF WORK/SPECIALTY DOLLAR AMOUNT CONTRACT <br /> DOLLARS <br /> A ! <br /> g 1 <br /> C 1 <br /> i <br /> D <br /> E • <br /> 12F TOTAL DOLLARS TO 120 TOTAL.PERCENT <br /> O9E'S OF CONTRACT i <br /> 13.SUBMITTED BY _.._._ 94,DATE 15.TITLE QF SUBMITTER <br /> .--�-t (� _► _ x xz, T{- <br /> 16,EEMAAIL'ADDD�DRk SOF S�U^,BMITTER 17.FAX NUMBtE�R^°'y 18�.PHONE NUMBER y� <br /> NOTE: THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION IN ALL STATE AND FEDERALLY <br /> FUNDED FDOT CONTRACTS. THE ANTICIPATED USE 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 00FICE, I i <br /> THE FOLLOWING SECTIONS ARE FOR FDOT USE <br /> i9.PROCESSED BY 20.DATE TO EO OFFICE 21.LETINR DATE 22.EXECUTED DATE 23.PRECON CONF DATE <br /> DLST <br /> 24.SUBMITTEDTOEO ❑ FAX ❑ EMAIL <br /> BY ❑ SHARED FOLDER <br /> Ep 25,INCLUDEB IN DBE PARIICIPATION REPORT OF ODN <br /> OFG <br /> _0.0470-3 <br />