6-04 - Exhibit B - 33B.pdf

Solicitation No. 2098066

DART Form 33B Page 1 of 11 Exhibit B

DALLAS AREA RAPID TRANSIT

EXHIBIT B

SPECIAL SOLICITATION INSTRUCTIONS and CONDITIONS

Table of Contents

1 INTRODUCTION AND PURPOSE OF SOLICITATION (B-100.01A, JAN 02)

2 EVALUATION AND BASIS FOR AWARD (B-100.03, JAN 02)

3 SUBMISSION OF PROPOSAL (B-100.14B, FEB 05)

4 PROPOSAL PREPARATION AND FORMAT (B-100.14SA, JUN 06)

5 PROPOSAL CONTENT AND EVALUATION FACTORS FOR AWARD, (B-100.14SB, AUG 04)

6 EVALUATION OF PROPOSALS AND SELECTION PROCEDURE (B-100.15D, JUN 05)

7 INCORPORATION OF OFFEROR’S PROPOSAL (B-100.16A, AUG 04)

8 QUESTIONS CONCERNING THE SOLICITATION

9 SUBMISSION OF PROPOSALS

10 SUBMISSION OF SCHEDULE OF SUBCONTRACTOR(S)/SUBCONSULTANT(S) (B-100.23, SEP 03)

ATTACHMENT 1 TO EXHIBIT B - SCHEDULE OF SUBCONTRACTOR(S)/SUBCONSULTANT(S)

1 Introduction and Purpose of Solicitation (B-100.01A, JAN 02)

(a) The Dallas Area Rapid Transit Authority (the "Authority" or "DART") is a public transportation agency providing an assortment of transportation services to 13 cities in the Dallas, Texas, Metroplex.

Transportation services include bus, an electric light-rail system, a commuter rail line, , ride-share programs, curb-side services for the mobility impaired, and transit educational services.

(b) The Authority is seeking sealed offers from qualified firms or individuals interested in providing contractor to provide turnkey service utilizing Software as a Service (SaaS) to manage the operations of the MUTD shared ride/on-demand service (Service)., as described in Exhibit H.

2 Evaluation and Basis for Award (B-100.03, JAN 02)

(a) Estimated Quantities (B-100.05B, AUG 04)

The quantities specified in the Schedule are estimates only, are used as a basis for determining award of the contract(s), and are not hereby purchased.

(b) Evaluation of Offers Inclusive of Options (B-100.06B, JUL 04)

The Authority shall evaluate offers for award purposes by including the total price for the basic requirement together with any option pricing, i.e., option pricing will be included in the evaluation for award purposes. Optional items shall not necessarily be purchased under this solicitation.

(c) Unit and Extended Pricing (B-100.08A, OCT 04)

Offerors shall insert the unit price and extended amount for each line item offered on the Schedule. If a line item is offered at “No Cost,” enter “No Cost” in the unit price column. Additionally, offerors shall calculate and insert the total price in the space provided on the Schedule.

(d) Right to Reject Materially Unbalanced Offers (B-100.09A, JUL 04)

The Authority reserves the right to reject offers that are materially unbalanced, i.e., that contain

DART Form 33B Page 2 of 11 Exhibit B unreasonably high unit prices for some items and/or unreasonably low unit prices for other items.

(e) All or None Pricing

Failure of an offeror to provide prices for all line items listed on the Schedule shall be cause for rejection of the entire offer.

3 Submission of Proposal (B-100.14B, FEB 05)

Offerors shall submit a proposal consisting of both technical and price proposal components in response to this solicitation.

(a) See the Solicitation, Offer and Award Form for the number of proposal copies to submit and for the date and time specified for receipt of offers.

(b) Technical proposals shall be uploaded to the Bonfire portal labeled “Technical Proposal”.

(c) Price proposals shall be uploaded to the Bonfire portal labeled “Price Proposal”.

4 Proposal Preparation and Format (B-100.14SA, JUN 06)

(a) Proposal documents shall be prepared in single-spaced type, on 8-1/2" x 11" pages, using one side of the paper only. Pages shall be numbered to show the page number and total number of pages in the proposal (e.g., Page 1 of 15, Page 2 of 15, etc.).

(b) All names and applicable titles shall be typed and printed where indicated on the various documents.

(c) Required entries on all proposal documents shall be typed using black ribbon, printed using dark printer ink, or legibly written in dark ink (no pencil).

(d) Unnecessarily elaborate proposals or lengthy presentations are not desired or required by the Authority.

(e) Proposal documents shall be set out in the Sections outlined below. A blank page should precede each Section with an index tab that identifies the appropriate Section.

Section 1 Introduction and Submittals Section 2 Qualifications of the Firm Section 3 Qualifications of the Staff Section 4 Work Plan Section 5 System and Equipment Performance Section 6 Exemptions/Deviations Section 7 Cost/Price Schedule

(f) Exceptions to, or variances from, any portion of the solicitation requirements contained herein, including the Statement of Work and/or Specifications, shall not be considered unless specifically identified in a separate document prepared solely for the purpose of comparing the requested exceptions or variances with the stated requirements. The document shall accompany the offeror’s proposal, so that the Authority may determine whether to accept or reject such exceptions or variances based on its content. Absent submittal of a separate document, no exceptions or variances shall be authorized.

(g) If a proposal is from:

an individual, sole proprietorship, or an offeror operating under a trade name, the proposal shall be signed by that individual;

a partnership, the proposal shall be executed in the partnership name and signed by all partners or by a

DART Form 33B Page 3 of 11 Exhibit B managing partner accompanied by evidence of that partner’s ability to sign for the partnership. The official address of the partnership shall be shown below the signatures;

a corporation, the proposal shall be executed in the corporate name by the president or vice-president (or other corporate officer accompanied by the evidence of that officer’s authority to sign for the corporation), and the corporate seal shall be affixed and attested by the corporate secretary or assistant secretary;

a joint venture or other type of teaming arrangement, the proposal shall list the names of all of the joint venture or teaming arrangement members, and each member’s official mailing address. It shall be executed by all of the members in the same manner as if they were individually submitting a proposal(s).

The signature portion of the proposal form shall be altered as appropriate for execution by the joint venture or teaming arrangement.

(h) Please limit your submission to a maximum of one hundred and fifty (150) pages for all sections not including Solicitation’s Exhibit A to H, L, V. A maximum two (2) page introductory letter may be submitted.

The remaining pages of supportive information may include graphs, charts, photos, references etc., and is totally at the offeror’s discretion, provided the total one hundred and fifty (150) page limit is maintained.

Proposals that exceed these limits may be excluded from consideration --- or --- Only the first one hundred fifty (150) pages will be evaluated.

5 Proposal Content and Evaluation Factors for Award, (B-100.14SB, AUG 04)

Proposals should be clear, concise, and include sufficient detail for effective evaluation.

(a) Proposals will be evaluated for award based on the following:

(1) Technical acceptability 700 Total Maximum Points (and)

(2) Price 300 Total Maximum Points For a total combined Technical and Price/Cost Points = 1,000.

(b) Technical proposals shall contain the sections described herein.

(c) Price proposals shall contain the Schedule (DART Form 33.202A) provided by the Authority for the offeror to submit its price proposal, unless otherwise specified in the solicitation. If cost data is required, offerors must also submit cost data in the format described elsewhere herein.

(d) Each price proposal shall be evaluated and scored on the basis of a 300-point maximum. Scoring shall be in accordance with the following formula:

Awarded Example:

Vendor Offered Price Points Awarded Company A $87,000 $87,000/$87,000 x 300 = 300 Points Awarded Company B $91,578 $87,000/$91,578 x 300 = 285 Points Awarded

(e) Factors and any subfactors described with relative weights or points will be evaluated to determine whether the proposal submitted shall be characterized as “Acceptable”, “Potentially Acceptable” (that is, susceptible of being made “Acceptable”), or “Unacceptable”. Evaluation factors (with the exception of the price proposal) are specifically keyed to the information requested in this provision.

(1) Section 1 - Introduction and Submittals In this section include, at a minimum, the following:

(a) The Solicitation, Offer and Award Form (DART Form 33.201);

(b) Exhibit A, completed and signed;

(c) Attachment 1 to Exhibit B - Schedule of Subcontractor(s)/Subconsultant(s), in accordance with the provision titled, "Submission of Schedule of Subcontractor(s)/ Subconsultant(s)”;

(d) Exhibit G, Attachment 1, Intent to Perform as a Subcontractor;

(e) Exhibit L, Business Questionnaire;

DART Form 33B Page 4 of 11 Exhibit B

(f) Exhibit U – Buy America Certificate

(g) Exhibit V, Employee Information Form;

(h) An introductory letter that should be addressed to and include:

(i) Dallas Area Rapid Transit P.O. Box 660163 Dallas, TX 75266-7235 Attn: Ricardo E. Medina, Contract Specialist;

(ii) an introduction of the prime contractor, members of a partnership, joint venture, or other teaming arrangement, whichever is applicable, and an introduction of all major subcontractors/subconsultants who may be involved in the performance of the work; and

(iii) a discussion of the primary business experience, length of time in business, ownership, office locations, specific location of the principal office from where the main work will be performed, contact information (i.e., contact names, telephone and facsimile numbers, and email addresses), and other information introductory in nature for each firm involved in making the proposal.

(h) A letter, as applicable, from the offeror's chief executive officer guaranteeing the key personnel named in the staffing plan will be assigned to the project, unless such employment is duly terminated. If substitutes or "backup" personnel are planned on a contingency basis, such personnel shall also be named with a similar guarantee of assignment.

(2) Section 2 - Qualifications of the Firm (150 Total maximum points)

Discuss offeror’s qualifications as a business entity, past performance, and experience with special emphasis on the following:

1. Provide two examples of the firm’s experience within the transit and/or transportation industries (federal, state, or local agencies) performance of work/service related or similar to ADA Microtransit services.

At a minimum, and in detail:

a. Describe offeror's role (Prime Contractor or Subcontractor), direct experience on projects of similar size, scope and complexity, and

b. Also discuss the qualifications of all other firms proposed to be utilized in the performance of the work (including joint venture members or major subcontractors/subconsultants), and clearly differentiate which qualifications listed relate to which firm.

2. Demonstrate the firm’s experience in the usage of technology similar to the Go Pass App or similar software.

3. Provide detailed examples of similar work with first and last-mile service at the rider and trip volume described in the statement of work.

4. Identify your firm’s capability to meet the ADA & Title VI regulations.

(3) Section 3 - Qualifications of Staff (150 Total maximum points)

Provide a staffing plan that identifies the project manager(s) and any other key personnel who will be assigned to the project. Also discuss the qualifications and experience of each key individual. At a minimum, include the following:

DART Form 33B Page 5 of 11 Exhibit B

1. Qualifications of management staff and all other key personnel responsible for the daily service.

At a minimum,

a) A detailed resumes of all key personnel/management assigned to this contract, inclusive of all relevant joint venture information;

b) Identify all subcontractors key personnel, outsourced or prime contractor’s directly hired.

Resumes must be complete and concise, featuring the training and experience that is most directly relevant to the task responsibility to which the individual will be assigned.

Resumes must be dated (e.g., dates of education, experience, employment, certification etc.) and must state the function(s) to be performed on the project by each of the key personnel.

2. Allocation of time to the project, performance of work under this solicitation and resulting contract by project manager(s) and key personnel.

Submit At a minimum discussion on percentage (%) of time to be committed to the project by each of the project manager(s) and designated key personnel.

3. Organization of the workforce and personnel utilization.

Submit, at minimum, an (i) organizational hierarchy and (ii) chain of command flow chart, showing company and staff assigned to this project i.e., Names of the Contractor(s), principal(s), manager, and senior personnel complete with a listing of all job classifications and the number of full and part-time, direct or outsourced employees in each job classification, to be used in the work performance. Also identify which job classifications relate to subcontractor personnel.

4. Submit previous work experience related with similar work detailing examples of meeting with the outlined KPI’s.

5. Provide an example of your firms hiring process to include the background check process.

(4) Section 4 - Work Plan (300 Maximum points)

Provide a detailed description of the Workplan and Project Approach of how the offeror plans to organize, perform the work and achieve DART’s’ objectives as detailed in this Solicitation and resulting contract.

The information submitted should include, but not be limited to: project timeline for each proposed milestone; clear demonstration on how these plans will influence daily operations, efficiency, and service areas; quantity of resources and cost control measures while illustrating their customer service philosophy.

The offeror will also include detailed information of their plan and approach to make working technology integration by day 1 of the contract, quality control/assurance plan, fraud prevention measures, data reporting, training programs, vehicle maintenance plans, and overall contract compliance. If applicable, Proposer is also expected to include verifiable references or information that will serve to highlight Proposer’s level of relative experience and knowledge.

Provide a description of how the offeror proposes to organize and perform the work. At a minimum, include the following:

1. Proposed approach and methodology of accomplishing, managing and ensuring program and cost control of the work required for this project and is relevant to Exhibit H

DART Form 33B Page 6 of 11 Exhibit B

Statement of Work, at the minimum reference the following areas:

i. Project Timeline

ii. Onboarding and Integration of Technology(ies)

iii. Mobilization Plan (including Testing and Soft Start Launch)

iv. Seamless Transition Plan and Continuity of Service for all areas of the project

v. Full Scale Operational Plan

vi. Demobilization (close-out) Plan

vii. Quality assurance

2. Demonstrate your Operational and Administrative plans and how you will manage them to deliver the required services. Your answer should at a minimum provide detailed information on processes that explicitly address but are not limited to:

i. Initial and On-going recruitment plan of personnel to ensure service quality i.e., sufficient staffing, experienced Project Management team members etc.

ii. Employee Onboarding and Retention Plan for personnel e.g., Driver, Project

Management team members etc.

iii. Operational Scalability in all areas of services e.g., number of drivers needed, number of vehicles needed to operate the service, including number of WAV’s (wheelchair accessible vehicles_

iv. Provide a sample of the NTD reports submitted.

v. Provide examples of collaboration with another firm who provides similar services.

vi. Provide details of the maintenance plan to include vehicle condition.

vii. Provide a sample of your firm’s drug and alcohol testing procedure.

3. Describe your process or procedure for administrative and operational situations such as but not limited to

i. Experience in transporting people with disabilities who require mobility devices

ii. Special Events

iii. Inclement Weather

iv. Not obeying Program Rules (e.g. trips go out of zone boundary)

v. Excessive Cancellation

vi. Fraud Activities (driver or passenger)

vii. Supply Issues on Adequate Driving personnel(s)

viii. Lost and Found

ix. Personnel(s) Inappropriate behavior

x. System/ Operational Failures

xi. Customers comments and complaints

4. Proposed approach to managing the work and ensuring program and cost control and quality control.

5. At a minimum, explain the quality control plan for the performance of work addressing all requirements of the Statement of Work. Discuss proposed approach for surveillance and inspection of work; acceptance, rejection, documentation, and resolution of deficiencies;

and corrective actions.

6. Overall Project Resources for performance and completion of work of the Firm.

At a minimum provide information that demonstrate the Offeror’s resources and capacity to perform the work/services Microtransit, required under this solicitation and resulting contract;

a) Human resources: number of skilled key personnel’s, their role and area of their expertise (e.g., Fleet Management, Call Center, etc.), and their assigned role.

DART Form 33B Page 7 of 11 Exhibit B

b) Financial Capabilities and Resources: demonstrating offeror’s ability to fully perform the financial terms and conditions of the solicitation or resulting contract. At the minimum provide the most recent/latest three (3) years Audited Financial Statements (not counted towards the 150-page limit and can be uploaded in the Requested information labeled “Audited Financials”) to determine firm’s financial capacity and stability.

c) Material Resources: number of existing vehicles, equipment, property facilities and software including the information on their quantity, specific type/specification and stating which are owned or leased physical address(es) of the vehicle, equipment property facility it is located. Authority may conduct a site visit to inspect and to validate information submitted.

The vendor shall provide a comprehensive mobilization plan detailing the personnel, equipment, materials, and other resources necessary to successfully execute the three-month startup phase.

(5) Section 5 - System Performance (100 Maximum points)

Provide proof or validation that demonstrates great customer centricity, efficiency and effectivity of proposed system(s) or business process(es) for this solicitation and resulting contract. Provide the information as it relates to all areas of service as stated in the Statement of Work. At the minimum include details of the system(s) or process(es) salient characteristics, performance metrics, parameter or standards, and other required information to assist evaluating its performance. This should include at a minimum,

(a) Proposed system’s performance validated in independent technical reports or manufacturers’ technical data sheets.

• Wait time for service to be provided averages 30 minutes or less, and be financially sustainable

• Travel time for shared ride service is no more than 2 times direct drive time

• Continuously meet a customer satisfaction rating standard agreed upon by DART and

Contractor after the first 90 days of full implementation of the contract.

• 80% rating by customers willing to recommend the service to family or friends on independent DART surveys of TNC riders.

(b) Proposed Software Systems related to multiple areas of this Solicitation and resulting contract, examples are not limited to Customer Relationship Management, Fleet Management, Scheduling, Booking, Dispatch etc.-

(c) Proposed Equipment or devices applicable in multiple areas of this Solicitation and resulting contract examples are not limited to Vehicles, Mobile Data Terminals (MDT), Automatic Vehicle Locators (AVL) or telematic devices, Drive Cams etc.-

(d) Required tools, equipment, facilities, spares, documentation, materials, inventory, and analyses to ensure supportability of the system, meeting the Technology requirements in Exhibit H.

(6) Section 6 - Exemptions / Deviations

Proposer shall state any exceptions to or recommended deviations from the requirements of this RFP, segregating "technical" exceptions from "contractual" exceptions. Where Proposer wishes to submit alternative approaches to meeting DART’s technical or contractual requirements, these should be thoroughly explained.

Proposer may also propose procedural or technical enhancements/innovations to the Scope of Work which do not materially deviate from the objectives of the project.

DART Form 33B Page 8 of 11 Exhibit B

Solicitation Document Paragraph/Page Requirement Rationale and suggested alternative

Impacts On

RFP, Applicable Identify the Proposers Schedule, Specifications, Document, Page, requirement or justification why Cost, Exhibits, Section, Paragraph, portion to which the the requirement Performance, Attachments, Amendment

Sentence exception is taken will not be met and its alternative

Other strategy or position

(7) Section 7 - Cost/Price Proposal (300 Total maximum points)

The reasonableness of the total cost proposal and the competitiveness of the proposed price will be considered in comparison with other offers received; adequacy of market data that in support of proposed costs and prices; reasonableness of unit prices and labor rates; and a logical market basis approach of proposed prices. Scores shall be mathematically calculated per Section 5 - Paragraph e. This must be submitted separately from technical proposal.

6 Evaluation of Proposals and Selection Procedure (B-100.15D, JUN 05)

(a) Upon receipt of proposals, which shall consist of both technical and price proposals, the Contracting Officer will initiate the evaluation and selection procedure described herein.

(b) Proposals shall not be publicly opened.

(c) The Contracting Officer will review the proposals to determine if they comply with the solicitation provisions and contain all required submittals.

(d) The Contracting Officer will conduct an evaluation of the technical proposals, or may appoint a Selection Committee that will evaluate the technical proposals and provide the scores to the Contracting Officer for consideration. In either case, the technical proposals will be evaluated applying the evaluation factor(s) set forth in the Proposal Content and Evaluation Factors for Award provision.

(e) The Contracting Officer will consider the evaluated technical score for each offeror’s proposal to determine whether that offeror’s proposal shall be characterized as technically “Acceptable”, “Potentially Acceptable” (that is, susceptible of being made “Acceptable”), or “Unacceptable”. Proposals evaluated as technically “Unacceptable” shall be rejected, and will receive no further consideration for award.

(f) After a complete evaluation of the initial technical and price proposals, for those found to be technically “Acceptable” or “Potentially Acceptable” by the Contracting Officer, the Contracting Officer may:

(1) Proceed directly to award of the contract based on the total scores received; or

(2) Request clarifications from offerors; and/or

(3) Request that offerors make oral presentations concerning their technical proposals.

The Contracting Officer will establish the specific criteria and parameters for oral presentations. Oral presentations shall not be considered discussions. They shall be used solely to facilitate evaluation of the submitted proposals to further determine their appropriate characterization. The Contracting Officer may then proceed directly to award of the contract; or

DART Form 33B Page 9 of 11 Exhibit B

(4) Reject any proposals then determined to be “Unacceptable”; and

(5) Invite those offerors whose proposals were determined to be “Acceptable” or “Potentially

Acceptable,” and in the competitive range considering their overall technical and price scores, to participate in discussions. The competitive range will consist of all proposals that have a reasonable chance of being selected for award.

Discussions may address either the technical or price proposal, or both. At the conclusion of discussions, the Contracting Officer will set a time and date for the submission of best and final offers. If an offeror chooses not to submit a best and final offer, its initial proposal, to include price, will be evaluated for award. After the date and time set for receipt of best and final offers:

(a) The Contracting Officer will evaluate the best and final offers (or the initial proposal if no best and final offer is submitted) with or without referring the technical proposal of the best and final offer to the Selection Committee for evaluation.

(b) The Contracting Officer will make a determination for award based upon the total points for both the technical and price components of each offeror’s best and final offer (or initial proposal if no best and final offer was submitted).

(c) The Authority reserves the right, during the selection procedure, to investigate the qualifications of all offerors under consideration; to confirm any part of the information furnished by an offeror; and/or to require other evidence of managerial, financial, or technical capabilities that are considered necessary for the successful performance of work under a resulting contract.

(d) Offerors are hereby reminded that the Authority reserves the right to award a contract following evaluation of initial proposals submitted. Offerors should therefore ensure that they submit their best technical and price proposals in their initial proposal submissions.

7 Incorporation of Offeror’s Proposal (B-100.16A, AUG 04)

(a) The Authority reserves the right to incorporate the successful offeror’s proposal into any resulting contract, by reference or full text. This includes any revisions and supplements through the date set for submission of best and final offers, if applicable. Additionally, any modification of the otherwise successful offer prior to award of the contract, which makes its terms more favorable to the Authority, will be considered and may be accepted.

(b) If, after contract award, it is discovered that changes were agreed to in writing during negotiations, but were not incorporated into the resulting contract, such changes shall be considered administrative in nature and incorporated by unilateral modification at no change in the contract cost or price, or other terms and conditions.

(c) To satisfy the contract requirements, the offeror shall adhere to the proposal approach accepted by the Authority.

8 Questions Concerning the Solicitation

Questions or requests for clarification may be submitted on the DART supplier portal in the Questions and Answer section of the solicitation event.

9 Submission of Proposals

Proposals will only be accepted electronically on the DART Supplier portal, https://dart.bonfirehub.com https://dart.bonfirehub.com/

DART Form 33B Page 10 of 11 Exhibit B

10 Submission of Schedule of Subcontractor(s)/Subconsultant(s) (B-100.23, SEP 03)

Each offeror should include a completed Schedule of Subcontractor(s)/Subconsultant(s) form provided as Attachment 1 to Exhibit B with their offer. The contents of the form may be a factor used in determining an offeror's responsibility.

DART Form 33B Page 11 of 11 Exhibit B

DALLAS AREA RAPID TRANSIT

Attachment 1 to Exhibit B - Schedule of Subcontractor(s)/Subconsultant(s)

Offerors shall provide information on all their prospective subcontractor(s)/sub-consultant(s) who submit bids/quotations in support of this solicitation. Excluding the "Subcontractor Demographic Data" column below, all other contents of this form may be a factor used in determining an offeror's responsiveness.

Project Name: MUTD – Shared Ride/On-Demand Service Solicitation Number: 2098066

Name of Prime Contractor: _______________________________________________________

NAMES AND ADDRESS(ES) OF

SUBCONTRACTOR(S)/SUBCONSULTANT(S)

TYPE OF WORK TO BE

PERFORMED

CERT. SBC/SBE

OR CERT. DBE

SUBCONTRACTOR

DEMOGRAPHIC

DATA

(for research only)

NAME:

ADDRESS:

PHONE:

FAX:

E-MAIL:

TAX ID #:

CONTACT PERSON:

TYPE OF WORK:

IF YES: DBE □

American Indian □ Asian □ Black □ Hispanic □ Native Hawaiian □ White □ 2+ Races □

Male □ Female □

AGE OF FIRM:

OR SBE □

DATE OF CERT.

: DBE

: SBE

NAME:

ADDRESS:

PHONE:

FAX:

E-MAIL:

TAX ID #:

CONTACT PERSON:

TYPE OF WORK:

IF YES: DBE □

American Indian □ Asian □ Black □ Hispanic □ Native Hawaiian □ White □ 2+ Races □

: SBE

NAME:

ADDRESS:

PHONE:

FAX:

E-MAIL:

TAX ID #:

CONTACT PERSON:

American Indian □ Asian □ Black □ Hispanic □ Native Hawaiian □ White □ 2+ Races □

: SBE

NAME:

ADDRESS:

PHONE:

FAX:

E-MAIL:

TAX ID #:

CONTACT PERSON:

DATE OF CERT.

: DBE

: SBE

American Indian □ Asian □ Black □ Hispanic □ Native Hawaiian □ White □ 2+ Races □

Name/Title of Person completing this form: ___________________________________

Signature____________________________________________ Date_____________________