Firm Name: Date: Date: Time of Call: Yes Yes Used Other □ □ □ No No MBE □ □ Mail Phone Spoke With: Used Non- □ □ □ MBE Classification Facsimile Mail □ □ (Check only if requesting Facsimile Left □ □ □ waiver of MBE subgoal.) Email Message □ □ African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification Firm Name: Date: Date: Time of Call: Yes Yes Used Other □ □ □ No No MBE □ □ Mail With: Used Non- □ □ □ MBE Classification Facsimile Mail □ □ (Check only if requesting Email Facsimile Left □ □ □ waiver of MBE subgoal.) Email Message □ □ African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification Please check if Additional Sheets are attached. GOOD FAITH EFFORTS DOCUMENTATION TO SUPPORT WAIVER REQUEST Part 3 Additional information regarding rejected MBE quotes – Page __ of ___ Contractor Project Description This form must be completed if Part 2 indicates that a MBE quote was rejected because the Bidder/Offeror is using a Non-MBE or is self-performing the Identified Items of Work. Provide the Identified Items Work, indicate whether the work will be self-performed or performed by a Non-MBE, and if applicable, state the name of the Non-MBE. Also include the names of all MBE and Non-MBE Firms that provided a quote and the amount of each quote. Describe Identified Self-performing or Amount of Name of Other Firms Amount Indicate Reason Why MBE Items of Work Not Using Non-MBE Non-MBE who Provided Quotes Quoted Quote Rejected & Briefly Being Performed by (Provide name) Quote & Explain MBE Whether MBE or (Include spec/section Non-MBE number from Bid/Proposal) Self-performing Price □ □ $_________ Capabilities □ Using Non-MBE __________________ Other □ □ MBE □ ________________ Non-MBE □
Firm Name: MBE Classification (Check only if requesting waiver of MBE subgoal.) African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification Date: □ Mail □ Facsimile □ Date: □ Phone □ Mail □ Facsimile □ Email Time of Call: Spoke With: □ Left Message □ Yes □ No □ Yes □ No □ Used Other MBE □ Used □ Firm Name: MBE Classification (Check only if requesting waiver of MBE subgoal.) African American-Owned Hispanic American- Owned Asian American-Owned Women-Owned Other MBE Classification Date: □ Mail □ Facsimile □ Email Date: □ □ Mail □ Facsimile □ Email Time of Call: With: □ Left Message □ Yes □ No □ Yes □ No □ Used Other MBE □ Used □ Please check if Additional Sheets are attached. GOOD FAITH EFFORTS DOCUMENTATION TO SUPPORT WAIVER REQUEST Part 3 – Additional information regarding rejected MBE quotes Page __ of ___ Contractor Project Description This form must be completed if Part 2 indicates that a MBE quote was rejected because the Bidder/Offeror is using a Non-MBE or is self-performing the Identified Items of Work. Provide the Identified Items Work, indicate whether the work will be self-performed or performed by a Non-MBE, and if applicable, state the name of the Non-MBE. Also include the names of all MBE and Non-MBE Firms that provided a quote and the amount of each quote. Describe Identified Items of Work Not Being Performed by MBE (Include spec/section number from Bid/Proposal) Self-performing or Using Non-MBE (Provide name) Amount of Non-MBE Quote Name of Other Firms who Provided Quotes & Whether MBE or Non-MBE Amount Quoted Indicate Reason Why MBE Quote Rejected & Briefly Explain □ Self-performing □ Using Non-MBE ________________ $_________ __________________ □ MBE □ Non-MBE □ Price □ Capabilities □ Other Non- Non-
TORFP-MBE-DFORMSrevised3.1.2017.docx