19-Subcontractor Participation Plan.pdf

Bu si ne ss E nt er pr is e Pr og ra m

Su bc on tra ct or

P ar tic ip at io n Pl an

SUBCONTRACTOR PARTICIPATION PLAN

ATTENTION:

You MUST list ALL anticipated subcontractors, regardless of their dollar amount or percent proposed, and regardless of whether they are certified or not.

You MUST fill out ALL applicable fields completely for the Prime and all subcontractors. Failure to provide complete and legible information on this form may result in your firm not receiving full certification credit.

Project Title: _____________________________________________________________ Today’s Date:________________

BIDDER/PROPOSER COMPANY INFORMATION BID/PROPOSAL AMOUNT DESCRIPTION OF PROJECT SERVICES

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: FEDERAL TAX ID #:

CONTACT NAME: EMAIL:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

SUBCONTRACTOR COMPANY INFORMATION $ PROPOSED % PROPOSED DESCRIPTION OF PROJECT SERVICES

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: FEDERAL TAX ID #:

CONTACT NAME: EMAIL:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: FEDERAL TAX ID #:

CONTACT NAME: EMAIL:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

Rev 09/22/2023

SUBCONTRACTOR COMPANY INFORMATION PROFILE INFORMATION $ PROPOSED % PROPOSED DESCRIPTION OF PROJECT SERVICES

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: EMAIL:

CONTACT NAME: FEDERAL TAX ID #:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: EMAIL:

CONTACT NAME: FEDERAL TAX ID #:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: EMAIL:

CONTACT NAME: FEDERAL TAX ID #:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: EMAIL:

CONTACT NAME: FEDERAL TAX ID #:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

SUBCONTRACTOR COMPANY INFORMATION PROFILE INFORMATION $ PROPOSED % PROPOSED DESCRIPTION OF PROJECT SERVICES

NAME: ETHNICITY:

ADDRESS: GENDER:

CITY/STATE/ZIP: EMAIL:

CONTACT NAME: FEDERAL TAX ID #:

TELEPHONE NO:

CERTIFICATION TYPE: ACDBE DBE DVBE MBE LBE LSBE SBE WBE

CERTIFYING AGENCY: CITY OF L.A. CALIF DGS CALTRANS METRO SBA

DVA USWCC NWBOC WBEC-WEST OTHER ___________________________

NAICS:

I certify under the penalty of perjury that the information contained on this form is true and correct and that the firms listed are the subcontractors anticipated to be utilized if this project is awarded to the above prime contractor. I agree to comply with any applicable provisions for additions and substitutions, and I further understand and agree that any and all changes or substitutions must be authorized by the LAWA Procurement Services Division prior to their implementation. An amended Subcontractor Participation Plan is required for any substitution or change to Subcontractors listed on the originally submitted Plan.

Participation Level(s) Proposed by Bidder/Proposer:

ACDBE

DBE

DVBE

LBE

LSBE

MBE/WBE

SBE

SIGNATURE DATE

Goal(s) Stated in the Request for Bid/Proposal:

ACDBE

DBE

DVBE

LBE

LSBE

MBE/WBE

SBE PRINT NAME TITLE PHONE