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<br />.... <br /> <br />. <br /> <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br /> <br />275-030-11A <br />EQUAL OPPORTUNITY OFFICE <br />04/05 <br /> <br />r'I <br /> <br />ANTICIPATED DBE PARTICIPATION STATEMENT <br /> <br />. <br /> <br />r, <br /> <br />Financial Project Number: <br /> <br />. <br /> <br />Contract Number: <br /> <br />..., <br /> <br />. <br /> <br />Federal Aid Project Number (if applicable): <br /> <br />.., <br />. <br /> <br />Prime Contractor Name: <br /> <br />Contract Dollar Amount: <br /> <br />n <br />. <br /> <br />Is the prime contractor a Florida Department of Transportation Certified Disadvantaged Business Enterprise (DB E)? <br />(yes 0 ) (no 0) <br /> <br />'1 <br />. <br /> <br />Expected amount of contract dollars to be subcontracted to DBE(s): $ <br /> <br />,., <br />. <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 />.., <br />. <br /> <br />S\ <br /> <br /> <br /> <br />o <br /> <br />DBE (8) Name <br /> <br />., <br />. <br /> <br />r"l <br />. <br /> <br />,.., <br />. <br /> <br />. <br /> <br />Submitted by: ~ 'U'!J UJ6l;tL Title: _Pt€1\ P5VT <br /> <br />..d - V C ~ CDmcrY)--I-. "Y'tt Telephone Numbe" c::E- ~ - 422b <br /> <br />3OS--~1- B~e; Date: lO~ <br /> <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 /> <br />..., <br /> <br />. <br /> <br />E-mail Address: <br /> <br />..., <br /> <br />Fax Number: <br /> <br />., <br />. <br /> <br />., <br />. <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 />..., <br /> <br />. <br /> <br />..., <br /> <br />. <br /> <br />February 2007 <br /> <br />00404-6 <br /> <br />03-4122.0. <br /> <br />., <br /> <br />. <br /> <br />)1 <br />