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1. FINANCIAL PROJECT N0. <br />1 2. FAP NO. <br />15. TITLB OF SUBMITTER <br />3, CONTRACT NO. <br />4. COUNTY(IES) <br />5. DISTRICT <br />17. FFAX NUMBER <br />18: PHONE NUMBER <br />/'yE�R�� <br />�W�`1-��1� � L.. -CJI •'i..+'ti—� �L ' lGi� . C.i��� �^ Vy I{r �1W `" • P 6� i] <br />NOTE: THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION. IN ALL STATE AND FEDERALLY <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 FDOT USE <br />1A .PROCESSED BY <br />20. DATE TO EO 0YNCE <br />B. PRIME CONTRACTOR NA(ME� <br />22. EXECUTED DATE <br />7. FEID NUMBER <br />DIST <br />., <br />+ n z <br />B. GONTRAC7 OLLAR AMOUNT <br />9. REVISION? IF YES, REVISION NUMBER: <br />14. IS THE PRIME CONTRACTOR A FLORIDA <br />CERTIFIED "DBE"? (DISADVANTAGED <br />BUSINESS ENTERPRISE) <br />,j NO <br />❑ YES <br />11. IS THE WORK OF THIS CONTRACT <br />CONSTRUCTION trOR MAINTENANCE ❑7 <br />12. ANTICIPATED DBE SUBCONTRACTS. <br />EQ I <br />DBE SUBCONTRACTOR or SUPPLIER <br />TYPE OF WORK/SPECIALTY <br />DOLLAR AMOUNT <br />PERCENT OF <br />CONTRACT <br />DOLLARS <br />2i <br />W TOTAL DOLLARS TO <br />0.00% <br />13`. SUBMITTED BY <br />14 .DATE <br />15. TITLB OF SUBMITTER <br />16. EMAIL ADDRE S OFQSU/i3mrr <br />17. FFAX NUMBER <br />18: PHONE NUMBER <br />/'yE�R�� <br />�W�`1-��1� � L.. -CJI •'i..+'ti—� �L ' lGi� . C.i��� �^ Vy I{r �1W `" • P 6� i] <br />NOTE: THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION. IN ALL STATE AND FEDERALLY <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 FDOT USE <br />1A .PROCESSED BY <br />20. DATE TO EO 0YNCE <br />21. LETTINO DATE <br />22. EXECUTED DATE <br />23. PRECON OQNF DATE <br />DIST <br />24.5U8MITTED TO EO <br />BY <br />❑ FAX ❑ EMAIL <br />❑ SHARED SOLDER <br />EQ I <br />25.I11CLUDED IN DBE PARTICIPATION REPORT OF MIDNY <br />OFC <br />