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<br />I <br /> <br />I <br /> <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br /> <br />275-030-11A <br />EOUAL OPPORTUNITY OFFICE <br />04/05 <br /> <br />ANTICIPATED DBE PARTICIPATION STATEMENT <br /> <br />I Financial Project Number: <br /> <br />Contract Number: <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />I <br /> <br />Federal Aid Project Number (if applicable): <br /> <br />Prime Contractor Name: <br /> <br />Contract Dollar Amount: <br /> <br />Is the prime contractor a Florida Department of Transportation Certified Disadvantaged Business Enterprise (OBE)? <br />(yes 0 ) (no 0) <br /> <br />Expected amount of contract dollars to be subcontracted to DBE(s): $ <br /> <br />It is our intent to subcontract <br />sub-contractors: <br /> <br />% of the contract dollars to DBE(s). Listed below are the proposed DBE <br /> <br />DBE (s) Name <br /> <br />Tvpe of Work/Specialty <br /> <br />Dollar Amount/Percentaqe <br /> <br />Submitted by: <br /> <br />Title: <br /> <br />E-mail Address: <br /> <br />Telephone Number: <br /> <br />Fax Number: <br /> <br />Date: <br /> <br />Note: This information is used to track and report anticipated OBE participation in all state and federally funded FOOT <br />contracts. The anticipated DBE amount will not become a part of the contractual terms. <br /> <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 /> <br />February 2007 <br /> <br />00404-6 <br /> <br />03-4122.0. <br />