10-O1 CONSULTANT PROPOSAL DBE COMMITMENT 1. Local Agency: 2. Contract DBE Goal: 3. Project Description: 4. Project Location: 5. Consultant's Name: 6. Prime Certified DBE: 8. DBE 7. Description of Work, Service, or Materials Certification 9. DBE Contact Information 10. DBE % Supplied Number Local Agency to Complete this Section 17. Local Agency Contract Number: 11. TOTAL CLAIMED DBE PARTICIPATION % 18. Federal-Aid Project Number: 19. Proposed Contract Execution Date: 20. Consultant’s Ranking after Evaluation: __________________________ IMPORTANT: Identify all DBE firms being claimed for credit, regardless of tier. Written confirmation of each listed DBE is Local Agency certifies that all DBE certifications are valid and information on required. this form is complete and accurate. 22. Date 12. Preparer's Signature 13. Date 21. Local Agency Representative's Signature 23. Local Agency Representative's Name 24. Phone 14. Preparer's Name 15. Phone 25. Local Agency Representative's Title 16. Preparer's Title DISTRIBUTION: Original Included with consultant’s proposal to local agency. – ADA Notice: For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) or write Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
10-O1 DBE 1. Local Agency: 2. Contract DBE Goal: 3. Project Description: 4. Project Location: 5. Consultant's Name: 6. Prime Certified DBE: 7. Description of Work, Service, or Materials Supplied 8. DBE Certification Number 9. DBE Contact Information 10. DBE % Local Agency to Complete this Section 11. TOTAL CLAIMED DBE PARTICIPATION % 17. Local Agency Contract Number: 18. Federal-Aid Project Number: 19. Proposed Contract Execution Date: 20. Consultant’s Ranking after Evaluation: __________________________ Local Agency certifies that all DBE certifications are valid and information on this form is complete and accurate. IMPORTANT: Identify all DBE firms being claimed for credit, regardless of tier. Written confirmation of each listed DBE is required. 21. Local Agency Representative's Signature 22. Date 12. Preparer's Signature 13. Date 23. Local Agency Representative's Name 24. Phone 14. Preparer's Name 15. Phone 25. Local Agency Representative's Title 16. Preparer's Title DISTRIBUTION: Original – Included with consultant’s proposal to local agency. ADA Notice: For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) or write Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814. CONSULTANT PROPOSAL COMMITMENT
10o1.docx