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k"", <br />k�a <br />�pe <br />t:K <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275- 030 -11A <br />ANTICIPATED DBE PARTICIPATION STATEMENT EQUAL OPPORTUNITY OFFICE <br />D4105 <br />Financial Project Number: <br />Contract Number: <br />Federal Aid Project Number (if applicable): <br />Prime Contractor Name: <br />Contract Dollar Amount: <br />Is the prime contractor a Florida Department of Transportation Certified Disadvantaged Business Enterprise (DBE)? <br />(yes 0 ) (no O ) <br />Expected amount of contract dollars to be subcontracted to DBE(s): $ <br />It is our intent to subcontract % of the contract dollars to DBE(s). Listed below are the proposed DBE <br />sub - contractors: <br />DBE (s) Name Type of Work/Specialty Dollar Amount/Percentage <br />Submitted by: <br />E -mail Address: <br />Fax Number: <br />Title: <br />Telephone Number: <br />Date: <br />Note: This information is used to track and report anticipated DBE participation in all state and federally funded FDOT <br />contracts. The anticipated DBE amount will not become a part of the contractual terms. <br />This form must be submitted at the pre- construction or pre -work conference. DOT staff must forward this to the <br />Equal Opportunity Office, 605 Suwannee Street, MS 65 Tallahassee, FL 32399 -0450 or fax to (850) 414 -4879. If <br />you have any questions, please contact the EOO at (850) 414 -4747. <br />February 2007 <br />[1111 � 1 <br />03-4122.D. <br />