Appendix J - DBE Form.pdf

DISADVANTAGED BUSINESS ENTERPRISE (DBE)

PARTICIPATION FORM

Failure to complete this form may result in your bid or proposal being deemed nonresponsive and rejected without any further evaluation.

(Make additional copies if more than two DBE firms are participating.)

1. The County and funding agencies strongly encourage participation by Disadvantaged Business Enterprises (DBE) for this contract (DBEs, WBEs and MBEs)

2. List the % level of DBE Participation proposed: ___% WBE ___% MBE ___% DBE Total DBE=___%

3. Describe, in detail, the responsibilities of each DBE participant (attach additional sheets, if necessary) (To be counted towards the DBE goal, a firm must either be certified or have applied for certification by the due date on the cover of this document.)

DBE Name: % of Total Contract:_____________

Address: ________________________________________________________________________

Contact Name: Phone #: _____________________

Detailed Description of Responsibilities: ________________________________________________

Is the business certified as an DBE by an agency participating in the Michigan United Certification Program (MUCP) _____ YES _____ NO If no, have they applied for certification with an agency participating in the MUCP _____ YES _____ NO. Proof of certification or documentation from a certifying agency confirming receipt of DBE certification application must be submitted with this form.

Is the Business an MBE ___ YES ___ NO? If yes, who certified the Business? ___ Wayne County ___

MDOT

Is the Business a WBE ___ YES ___ NO? If yes, who certified the Business? ___ Wayne County ___

MDOT

Include the following (if applicable):

• The support (financial, technical, management, training, etc.) provided by the Proposer to each DBE partner.

• A copy of the documents that contain the proposed legal relationship between Proposer and each DBE participant (if applicable).

• Provide a resume for the principal(s) of the firms identified above.

DBE Name: % of Total Contract: _________________

Address: _____________________________________________________________________________

Contact Name: Phone #: __________________________

Detailed Description of Responsibilities:_____________________________________________________

Is the business certified as an DBE by an agency participating in the Michigan United Certification Program (MUCP) _____ YES _____ NO If no, have they applied for certification with an agency participating in the MUCP _____ YES _____ NO. Proof of certification or documentation from a certifying agency confirming receipt of DBE certification application must be submitted with this form.

Is the Business an MBE ___ YES ___ NO? If yes, who certified the Business? ___ Wayne County ___ MDOT Is the Business a WBE ___ YES ___ NO? If yes, who certified the Business? ___ Wayne County ___ MDOT

Include the following (if applicable):

• The support (financial, technical, management, training, etc.) provided by the Bidder to each DBE partner.

• A copy of the documents that contain the proposed legal relationship between Bidder and each DBE participant (if applicable).

• Provide a resume for the principal(s) of the firms identified above.

For assistance, or for more information on the DBE program or the MUCP, contact Human Relations at 313-224-5021.