AffirmativeMarketProgramAMPPlanForm.doc

AFFIRMATIVE MARKET PROGRAM (AMP) PLAN FORM

Pursuant to Executive Order 390, any contract with a potential financial benefit of $50,000 or more requires a bidder to complete applicable sections of this form and include the required attachments for consideration in the scoring of their submission for any contracting opportunity with the Commonwealth of Massachusetts.

Bidders must submit one form for each M/WBE AMP Relationship.

Bidder Name:

Contact Name:

Phone:

Fax:

Email address:

Company Address:

Is bidder SOMWBA certified? N/A FORMCHECKBOX

Yes FORMCHECKBOX

No FORMCHECKBOX Applied for certification FORMCHECKBOX

Affirmative Market Program Partner (not bidder)

M/WBE Contact Name:

M/WBE Company Name: M/WBE Company Address:

M/WBE Telephone: M/WBE Email:

AMP Partner’s SOMWBA Certification Status. Please Check Only One Per Form:

MBE FORMCHECKBOX

WBE FORMCHECKBOX

M/WBE FORMCHECKBOX

M/W Non Profit FORMCHECKBOX

Applied for certification FORMCHECKBOX

Certification Expiration Date (copy of certification letter must be attached): _______________________________________________

Check type of business relationship here that applies to AMP Partner and complete appropriate section below (1-5):

FORMCHECKBOX

1. Subcontract: include verification of expenditure commitments and written agreement.

FORMCHECKBOX

2. Growth & Development: enclose plan for education, training, mentoring, resource sharing, other initiatives.

FORMCHECKBOX

3. Ancillary: submit verbal or written expenditure commitments.

FORMCHECKBOX

4. Past Performance: credit for past expenditures with certified M/WBEs (for previous 2 years).

FORMCHECKBOX

5. Additional Creative Initiatives: further use of at least one certified MBE and one WBE AMP Partner.

1. Please complete this section ONLY if the business relationship is Subcontract (as defined within the scope of the RFR):

Note: All Subcontracting Partnerships require a written agreement between bidder & M/WBE that includes a description of all commodities or services to be acquired from subcontractor and to be presented as part of the AMP Plan submission. It is required that bidders commit a specific dollar amount or a minimum percentage of dollars earned through an awarded contract.

Committed Expenditures or Percentage Year 1:

Committed Expenditures or Percentage Year 2:

Committed Expenditures or Percentage Year 3:

Committed Total Expenditures or Percentage For All Years In the Contract

2. Please complete this section ONLY if the business relationship is Growth & Development:

Note: Bidders should provide a narrative here that describes your approach in building the capacity of the M/WBE, including deliverables or measurable outcomes and anticipated dates of completion which can be validated during the contract. (Attach additional pages as necessary):

Updated 11/1/05

AMP Form

3. Please complete this section ONLY if the business relationship is Ancillary:

Note: Bidders should provide a description of commodities or services Ancillary AMP Partner will provide (continue on additional pages as necessary):

Committed Expenditures: Year 1: $

Committed Expenditures: Year 2: $

Committed Expenditures: Year 3: $

Committed Total Spend for Use in Contract:

Description of commodities/services to be provided by Ancillary Partner:

4. Please complete this section for consideration ONLY relating to Past Performance (or historical spending with certified M/WBEs within the last 2 years):

List Name (s) of Certified M/WBE Vendor (s):

Circle Certification Status of Vendor (s): MBE WBE M/WBE MNPO WNPO

Description of all expenditures for commodities or services (attach additional pages as necessary):

Reporting Year: Total Expenditure:

Reporting Year: Total Expenditure:

5. Please complete this section for consideration ONLY relating to any Additional Incentives:

Please provide a description of any current creative approaches to partnering with certified businesses (attach additional pages as necessary):

Certification: I hereby certify under the pains and penalties of perjury that the information above is correct, to the best of my knowledge:

Signature of Authorized Signatory of Bidder:

Date:

Print Name:

Title:

Business Name: Business Address:

Updated 11/1/05

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AMP Form

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