OFFICE OF ECONOMIC OPPORTUNITY CHANGE ORDER PARTICIPATION FORM Name of Contractor/Consultant Project Title: Date: SBE, Firms Name Phone # Scope of Work to be subcontracted Dollar Value of (indicate if the contract will include labor Change Order & material) Code Code Description Total Dollar Value [$] Percentage of Contract Amount as a result of the Change Order[%] _________________ ___________________ AA African American Participation HANA Hispanic, Asian, Native American Participation _________________ ___________________ _________________ ___________________ WBE Women Owned Participation SBE Small Business Enterprise Participation _________________ ___________________ TOTAL Please attach the justification letter to this form along worth any necessary backup data. ADDITIONAL INFORMATION: _____________________________________________________________________________________ Signature: Title: __________________________________ _____________________________________ OEO FORM 6 Revised 3/2015
OFFICE OF ECONOMIC OPPORTUNITY CHANGE ORDER PARTICIPATION FORM Name of Contractor/Consultant Project Title: Date: SBE, Firms Name Phone # Scope of Work to be subcontracted (indicate if the contract will include labor & material) Dollar Value of Change Order Code Code Description Total Dollar Value [$] Percentage of Contract Amount as a result of the Change Order[%] AA African American Participation _________________ ___________________ HANA Hispanic, Asian, Native American Participation _________________ ___________________ WBE Women Owned Participation _________________ ___________________ SBE TOTAL Small Business Enterprise Participation _________________ ___________________ Please attach the justification letter to this form along worth any necessary backup data. ADDITIONAL INFORMATION: _____________________________________________________________________________________ Signature: __________________________________ Title: _____________________________________ OEO FORM 6 Revised 3/2015
FE%2004%20Inst%20to%20Bidrs%2000101-v4%203-20-15.docx