FORM 6 - DBE_SBE_DVBE SUPPLIER_BROKER QUESTIONNAIRE.pdf

FORM 6 - DBE/SBE/DVBE SUPPLIER/BROKER QUESTIONNAIRE

(Submit for each anticipated product, materials, or supplies to be provided) 49 CFR Part 26.55

Project Number:

Project Name:

Prime Name:

□DBE □SBE □DVBE Business Name (check one):

Name of Product, Material, or Supply:

Description:

(Circle One) 1.) In the usual course of business, does the DBE, SBE, or DVBE firm regularly engage in the purchase and sale or lease of the products, materials or supplies involved in the project, for which DBE credit is being sought?

Yes No

2.) Does the DBE, SBE, or DVBE firm maintain the products, materials, or supplies in a warehouse? Yes No

3.) Will the DBE, SBE, or DVBE firm supply bulk or specialty items? Yes No a.) If yes, does the DBE, SBE, or DVBE own/operate distribution equipment for the bulk or specialty items? Yes No b.) If DBE, SBE, or DVBE does not own/operate distribution equipment, do they have a long term lease agreement for the equipment (not on an ad-hoc or contract by contract basis)?

Yes No

4.) Please describe how the DBE, SBE, or DVBE will pay for products, materials, or supplies:

5.) Explain the DBE, SBE, or DVBE firm's process for negotiating and obtaining prices for the products, materials, or supplies:

6.) How will the DBE, SBE, or DVBE firm determine quality & quantity needed on the project?

7.) How will the DBE, SBE, or DVBE deliver products, materials, or supplies?

8.) Please list the equipment the DBE, SBE, or DVBE uses for distributing the products, material or supplies:

The authorized signer declares that the information on this form and any attachments, are current, complete and accurate.

Authorized Signature: Date:

Printed Name:

Title: