RFP 27-12 MBE Form.pdf

COLUMBIA ASSOCIATION

MINORITY BUSINESS ENTERPRISE (MBE) FORM

Project: On-Call Wood Floorong Services RFP No.: 27-12

Instructions: The Minority Business Enterprise (MBE) Form must be submitted with the bid/proposal. Failure to accurately complete and submit this form may deem the bid unresponsive or may determine that the proposal cannot be selected for contract award.

1. The Contractor shall attempt to achieve Twenty-three percent (23%) or greater participation from certified Minority Business Enterprise firms for the performance of this contract, in accordance with CA’s organizational goal. This may be in the form of a prime or subcontractor participation.

2. The Contractor is encouraged to use a diverse group of subcontractors and suppliers from the various MBE classifications. All MBE firms must be certified as specified in the Minority Business Enterprise paragraph of this solicitation. Only certified MBE firms shall be counted toward this requirement. Firms may obtain a listing of certified Minority Business Enterprise firms from the Maryland Department of Transportation (MDOT) directory which can be found through the following link: https://mbe.mdot.maryland.gov/directory/

In connection with the bid/proposal submitted in response to Solicitation No. _______________, I affirm the following:

☐ I acknowledge and intend to meet IN FULL the overall certified Minority Business Enterprise (MBE) participation goal of

Twenty-three percent (23%). For each MBE firm utilized the proposer must provide the following information to include a copy of the MBE firm’s certification documentation, the MBE firm’s name, address and tax identification number.

Total African American MBE Participation: $_____________ Total Asian American MBE Participation: $_____________ Total Hispanic American MBE Participation: $_____________ Total Women-Owned MBE Participation: $_____________ Total Disabled MBE Participation: $_____________ Total MBE Participation (include all categories): $_____________ Total Contract Value: $_____________ Total Percentage of MBE Participation _____________%

OR

☐ After making good faith outreach efforts prior to making this submission, I conclude that I am unable to achieve the MBE participation goal. Firm must provide the name, business address and phone number of all Minority Business Enterprise firms that were contacted to provide goods or services under this contract. At least three firms must be listed.

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

I affirm that I have reviewed this form and certify that the information provided is true to the best of my knowledge, information and belief.

Firm Name: _______________________________________________________Date: ____________________

Signature of Authorized Firm Representative: ______________________________________________________

Printed Name and Title: _______________________________________________________________________

Phone (______) _______ - ___________

Address: ___________________________________________________________________________________

E-mail: _____________________________________________________________________________________ https://mbe.mdot.maryland.gov/directory/