2-04. MBE Attachment B - Participation Schedule - Non-Wage Scale.pdf

ATTACHMENT B

NON-WAGE SCALE

MBE PARTICIPATION SCHEDULE

This document must be included with the bid or offer. If the bidder or offeror fails to submit this form with the bid or offer as required, the procurement officer shall deem the bid non- responsive or shall determine that the offer is not reasonably susceptible of being selected for award.

October 1, 2017

1. Prime Contractor’s Name 2. Prime Contractor’s Address/Telephone Number

3. Project/School Name 4. Project/School Location

5. LEA Name:.

PSC Number:

6. Base Bid Amount $ _________________________

Acceptance Alternates $ _________________________

Total $ _________________________ 7a.

Minority Firm Name: ____________________________________________

Minority Firm Address: ___________________________________________ Telephone Number: _____________________________

MDOT Firm Certification Number: ___________________________________ NAICS Code: __________________________________ □African American □ Asian American □ Native American □ Women □ Hispanic □ Disabled

Subcontractor Firm (Select One)

Allowable Percentage

Percentage of Total Contract

Subcontractor Dollar Amount

Participation Amount

MDOT Certified Firm 100% $ $

MDOT Certified Prime Contractor

50% of established goal OR $ $ 100% of one subgroup contract subgoal

MDOT Certified Supplier, Wholesaler and Regular Dealer

60% $ $

7b Minority Firm Name: ____________________________________________

Minority Firm Address: ___________________________________________ Telephone Number: _____________________________

MDOT Firm Certification Number: ___________________________________ NAICS Code: __________________________________ □African American □ Asian American □ Native American □ Women □ Hispanic □ Disabled

Subcontractor Firm (Select One)

Allowable Percentage

Percentage of Total Contract

Subcontractor Dollar Amount

Participation Amount

MDOT Certified Firm 100% $ $

MDOT Certified Prime Contractor

50% of established goal OR $ $ 100% of one subgroup contract subgoal

MDOT Certified Supplier, Wholesaler and Regular Dealer

60% $ $

7c Minority Firm Name: ____________________________________________

Minority Firm Address: ___________________________________________ Telephone Number: _____________________________

MDOT Firm Certification Number: ___________________________________ NAICS Code: __________________________________ □African American □ Asian American □ Native American □ Women □ Hispanic □ Disabled

Subcontractor Firm (Select One)

Allowable Percentage

Percentage of Total Contract

Subcontractor Dollar Amount

Participation Amount

MDOT Certified Firm 100% $ $

MDOT Certified Prime Contractor

50% of established goal OR $ $ 100% of one subgroup contract subgoal

MDOT Certified Supplier, Wholesaler and Regular Dealer

60% $ $

8. MBE Total Amount 9. Total MBE Percent of Entire Contract

10. Form Prepared by:

Name: ____________________________________________________ Title: ____________________________________________________ Date: ____________________________________________________

11. Reviewed and Accepted by Board of Edu. MBE Liaison Name: ___________________________________

Title: ____________________________________ Date ____________________________________

Total MBE Participation: $ ___________________ _____________% Total African-American Participation: $ ___________________ _____________% Total Women Owned MBE Participation: $ ___________________ _____________% Total Other Participation: $___________________ _____________%

ORIGINAL[ ]

REVISED[ ]