Total Direct MBE Participation MBE Indirect Participation Dollar Amount Percent Amount MBE Firm Name Participation ($) Participation (%) Total Indirect MBE Participation WBE Proposal (Direct & Indirect) WBE Direct Participation Dollar Amount Percent Amount WBE Firm Name Participation ($) Participation (%) Total Direct WBE Participation WBE Indirect Participation Dollar Amount Percent Amount WBE Firm Name Participation ($) Participation (%) Total Indirect WBE Participation The Prime Contractor designates the following person as its MBE/WBE Liaison Officer: (Name- Please Print or Type) (Phone) I DO SOLEMNLY DECLARE AND AFFIRM UNDER PENALTIES OF PERJURY THAT THE CONTENTS OF THE FOREGOING DOCUMENT ARE TRUE AND CORRECT, THAT NO MATERIAL FACTS HAVE BEEN OMITTED, AND THAT I AM AUTHORIZED ON BEHALF OF THE PRIME CONTRACTOR TO MAKE THIS AFFIDAVIT. ______________________________________________ (Name of Prime Contractor Print or Type) – State of:_____________________________________
Total Direct MBE Participation MBE Indirect Participation MBE Firm Name Dollar Amount Participation ($) Percent Amount Participation (%) Total Indirect MBE Participation WBE Proposal (Direct & Indirect) WBE Direct Participation WBE Firm Name Dollar Amount Participation ($) Percent Amount Participation (%) Total Direct WBE Participation WBE Indirect Participation WBE Firm Name Dollar Amount Participation ($) Percent Amount Participation (%) Total Indirect WBE Participation The Prime Contractor designates the following person as its MBE/WBE Liaison Officer: (Name- Please Print or Type) (Phone) I DO SOLEMNLY DECLARE AND AFFIRM UNDER PENALTIES OF PERJURY THAT THE CONTENTS OF THE FOREGOING DOCUMENT ARE TRUE AND CORRECT, THAT NO MATERIAL FACTS HAVE BEEN OMITTED, AND THAT I AM AUTHORIZED ON BEHALF OF THE PRIME CONTRACTOR TO MAKE THIS AFFIDAVIT. ______________________________________________ (Name of Prime Contractor – Print or Type) State of:_____________________________________
Exhibit-A-MBE-WBE-Special-Conditions.docx