MBEWBE Form.pdf

Department Of General Services

MBE/WBE SUBCONTRACTOR AND SUPPLIER SOLICITATION & COMMITMENT FORM

Bureau of Minority and Women Business Opportunities

STD-168 Rev. 06/02/08 Page 1 of 2

IMPORTANT NOTE: The purpose of this Form is to document the bidder’s compliance with the Commonwealth’s non-discrimination program and to determine whether the bidder has discriminated in the selection of subcontractors and suppliers. Failure to complete this Form and submit it with the bid will be sufficient cause for rejection of the bid as NOT RESPONSIVE. Bidders must solicit BOTH MBE and WBE supplier participation for any work the bidders intend to subcontract or for any materials required to perform the contract.

Your Company Information:

Company Name: Contact Person:

Address:

Tel #: Fax #: E-Mail:

SAP Vendor #:

Contract/Solicitation Information:

Contract/ Solicitation

Number:

Bid Opening

Date: Bid Amount (Bid Base #1):

ALL FIRMS SOLICITED OR WHICH HAVE PROVIDED UNSOLICITED QUOTES MUST BE INCLUDED ON THIS FORM (1)

Subcontractor/Supplier Company Information

• Company Name, Address, Zip Code

• Tel. No. with Area Code

• Contact Person’s Name

(2) MBE, WBE or

MWBE

(3) Type of Work to be Performed and/or Material to be Supplied

(4) Total Dollar

Amount of Quote Received

(5) Total

Commitment Dollar Amount

Select One

Select One

Select One

Select One

(1) Enter the official subcontractor or supplier’s company name exactly as it appears on the Dept. of General Services (DGS) website list of certified MBEs/WBEs. Do not use D/B/A (Doing Business As) name.

(2) Indicate whether the firm is DGS certified MBE or WBE. If the firm is both, the bidder will receive credit for the firm as either an MBE or a WBE.

(3) Briefly describe the specific type of work to be performed and/or materials to be supplied by the listed DGS certified MBE or WBE. In order to count towards reaching the MPLs, bidders must solicit DGS certified MBEs/WBEs in the areas in which they are certified. For example, if an MBE/WBE is certified for electrical supplies and the bidder lists plumbing supplies, the bidder will not receive credit. Geographical location may not be used as a reason for limiting solicitation.

(4) Enter the total dollar ($) amount of the quote received. If the quote was received in the form of unit prices or hourly rates, a total dollar amount must still be provided. If the subcontractor did not respond to the bidder, the bidder must indicate “No Response.” Copies of all MBE/WBE quotes must be submitted with the bid.

NOTE: Minimum Participation Levels (MPLs): MBE – 5%; WBE – 3% A presumption of non-discrimination may be made if the dollar commitments to MBEs / WBEs reflect these minimum participation

Department Of General Services

MBE/WBE SUBCONTRACTOR AND SUPPLIER SOLICITATION & COMMITMENT FORM

Bureau of Minority and Women Business Opportunities

STD-168 Rev. 06/02/08 Page 2 of 2

(5) Enter the total dollar ($) amount of the contractual commitment made to the listed MBE/WBE. If the bidder does not use the total quote from a MBE/WBE because a lower priced quote was received, the bidder must submit a copy of the lower priced quote with its bid. On partial commitments, the bidder must explain why only a partial commitment was made and must submit a copy of the lower priced quote.

If the Bidder does not intend to utilize any subcontractors or suppliers in the performance of this contract, please check this box.

CONFIRMATION CHECKLIST FOR SUBMISSION OF FORM STD-168 AND OTHER DOCUMENTATION

The Bidder must complete and submit Form STD-168 with its bid. If the supplier is providing their response through SRM, this completed form may be electronically attached and submitted with the bid.

Along with the Form STD-168, the Bidder must include all solicited and unsolicited quotes received by the Bidder from MBEs and WBEs as long as the quotes are within the scope of work.

The Bidder’s contact with MBE/WBE subcontractors and suppliers should be a minimum of (10) days prior to bid opening date. This will ensure that MBEs/WBEs have sufficient time to prepare a quote. Ten days is a guide; however, adequate time must be provided to all subcontractors and suppliers to respond.

If the minimum participation levels (MPLs) for this project are not achieved, you must provide a written explanation explaining the failure to achieve the MPLs for MBEs and/or WBEs. Failure to do so will result in rejection of the bid.

If there are any questions/comments concerning this form, please contact the issuing agency contracting officer. If additional forms are needed, you are permitted to photocopy form. If the supplier is providing their response through SRM, this completed form may be electronically attached and submitted with the bid.

Approved Denied Comments:

Reviewer: Date:

OFFICIAL USE ONLY