1197216_9- Exhibit D-2 DBE Firm Data Sheet IFB 208-22-03.pdf

DBE FORM 1

Purchase < $100,000

301 East Belt Blvd. • Richmond, VA 23224

FIRM DATA SHEET

Company's Full Legal Name

Firm's Address

City State Zip Code

Telephone Number Fax Number E-mail Address

Contact Name (First & Last)

Product/ Service Category Age of Firm

Firm’s DBE* Status: DBE � Certification expiration date _______________________

Gender: Male � Ethnicity : Black American � Asian Pacific American � Female � Hispanic American � Non-minority women � Native American � Other � _____________ Subcontinental Asian American �

Non-DBE � *Disadvantaged Business Enterprise (DBE) Certification by VDOT only

Annual Gross Receipts

For the Firm's fiscal year ending ___________________________ (Date)

PLEASE CHECK THE APPROPRIATE BRACKET

� Less than $100,000

� $100,000 to $250,000

� $250,000 to $500,000

� $500,000 to $1 million

� $1 million to $2 million

� $2 million to $5 million

� $5 million to $10 million

� $10 million or greater

FOR OFFICE USE ONLY

Department

Request Date

PO#

Contractor � Sub-contractor � Contract Goal Yes ___ No ___

CONFIDENTIATLITY NOTE: The information entered on this form is legally privileged and confidential information intended solely for the use of GRTC Transit System. This information, in accordance with federal guidelines, will be kept strictly confidential and will only be provided to a third party with the firm's written consent.