Attachment K-2 - ACDBE Vendor Information Forms.pdf

Vendor Information Form (Concessions/Management Contract)

This form is intended to be used to identify all ACDBE & Non-ACDBE firms that will be participation on the Prime Contract. A separate Vendor Information Form must be completed for each firm that will be working or otherwise participation on the prime contract by operating all or part of the concession or by providing goods or services as a prime and/or subcontractor (including suppliers). Duplicate this form as needed.

All sections of this form must be completed; no fields should be left blank. If appropriate, enter "not applicable" or "N/A".

Ensuring the accurate completion of this subcontractor form is the responsibility of the prospective prime contractor. Failure to timely arrange for each prospective firm to complete this form as part of the proposal may result in the proposal being deemed non-responsive. Note: Both the prime and firm authorized representatives must sign this form.

Description of Prime Contract & Vendor Information

1. Contract Name

4. Firm Name & Address

WCAA Vendor Form (Concessions/Management Contracts) - Revised 11/8/2017 Page 1 of 2

10.Firm Primary Contact Phone Number & Email

2. Prime Concessionaire Name

6. DBE/ACDBE? Yes No If "yes", list NAICS codes of work to be performed:

Detailed description of the work to be performed by Firm:

12. Percent of contract the Firm is anticipated to perform:

Certification & Signature Under penalty of perjury, I certify that:

1) I am authorized to execute this form on behalf of my firm;

2) I have conducted reasonable due diligence in collecting the information to be submitted on or with this form; and

3) I understand that this form contains material statements relied upon by the Airport Authority as a part of their decision-making process, and, based on my knowledge, the foregoing form does not contain any untrue information or omit any material fact necessary to make the information contained herein true and complete.

9. Firm Primary Contact Name/Title

5. Fed Tax ID

7. Relationship, if any, between Prime Contractor & Firm:

8. Owners/Partners/Corporate Director/Principal Stockholders(>5% stock holdings) of Firm:

11.

Prime Contractor Authorized Representative - Printed Name Title Signature Date

Firm (First Tier) Firm Name (First Tier)

Authorized Representative - Printed Name Title Signature Date

Firm (Second Tier) Firm Name (Second Tier)

Authorized Representative - Printed Name Title Signature Date

(if applicable)

WAYNE COUNTY AIRPORT AUTHORITY ATTACHMENT

Firm Name Owner's Name Firm Address Main Contact:

Phone # Email

Anticipated % of Contract

DBE/ACDBE Status (verified via MUCP Directory)

NAICS

Codes

Age of Firm Annual Gross

Receipts

DBE/ACDBE FIRMS ONLY

WCAA Vendor Summary Form - Revised 10/31/2017 Page 2 of 2

Vendor Summary Form (Bidders List)

WAYNE COUNTY AIRPORT AUTHORITY ATTACHMENT

The purpose of this form is to provide data about the universe of DBE/ACDBE and non-DBE/ACDBE firms who seek to work on WCAA agreements for use in helping to set overall DBE/ACDBE Program Goals. This form must include all Firms that are anticipated to participate on the Prime Contract and must be accompanied by a Vendor Information Form for each Firm listed. Duplicate this form as needed.

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

Non-DBE/ACDBE

DBE/ACDBE

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than $500k $500k - $1 mil $1 - 2 mil $2 - 5 mil

> than 5 mil

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs

< than 1 Yr 1-3 Yrs 4-7 Yrs 8-10 Yrs > than 10 Yrs