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MSD FORM A
MET ROPOLITAN ST. LOUIS SEW ER DIST RICT
SUBCONT RACTOR UTILIZATION EVALUATION FORM
BUILDING, NON-BUILDING, STATE FUNDED,
FEDERAL FUNDED CONSTRUCTION
Bidder Name: ___________________________________________________________________________
Project Name/Number : ____________________________________________________________________
1) M W B E Fir m N a m e Certified B y: M B E or WB E:
Subcontractor to (check one): Prime (Tier 1 Subcontractor) ___ Other Subcontractor’s Name ____________________
Description of Materials/Service/Work Participation $
M aterials /Supplies inc luding Lab or or Inst allation (100%)
Se rv ice Pro vider/I nstaller (Prov iding E quipment & Material ) (100%) ____________________________
H auling Services (100%) (Requires ownership of at least 1 operating truck )
Supplier/Distributor (60%) (No Advanced Payments)
Broker/Dealer (3%) ____________________________
Other (i.e. Protégé) (Agreement Required) ___________________________
$________________
$________________
$________________
$________________
$________________
$________________
2) M W B E Fir m N a m e Certified B y: M B E or WB E:
Subcontractor to (check one): Prime (Tier 1 Subcontractor) ___ Other Subcontractor’s Name ____________________
Description of Materials/Service/Work Participation $
M aterials /Supplies inc luding Lab or or Inst allation (100%)
Se rv ice Pro vider/I nstaller (Prov iding E quipment & Material ) (100%) ____________________________
H auling Services (100%) (Requires ownership of at least 1 operating truck )
Supplier/Distributor (60%) (No Advanced Payments)
Broker/Dealer (3%) ____________________________
Other (i.e. Protégé) (Agreement Required) ___________________________
$________________
$________________
$________________
$________________
$________________
$________________
3) M W B E F ir m N a m e Certified B y: M B E or WB E:
Subcontractor to (check one): Prime (Tier 1 Subcontractor) ___ Other Subcontractor’s Name ____________________
Description of Materials/Service/Work Participation $
M aterials /Supplies inc luding Lab or or Inst allation (100%)
Se rv ice Pro vider/I nstaller (Prov iding E quipment & Material ) (100%) ____________________________
H auling Services (100%) (Requires ownership of at least 1 operating truck )
Supplier/Distributor (60%) (No Advanced Payments)
Broker/Dealer (3%) ____________________________
Other (i.e. Protégé) (Agreement Required) ___________________________
$________________
$________________
$________________
$________________
$________________
$________________
************************************************************************************************************
Attachments to Form A: Supplier Agreement for Sub contractor___________________________
Distributor Agreement for Subcontractor _________________________
Leasing Agreement for Subcontractor ___________________________
Mentor/Protégé Agreement for Subcontractor _____________________
Other Agreement ___________________________________________
MWBE SUBCONTRACT OR TOT AL $ _____________________________________
*Bidder is responsible to verify that MWBE subcontractors are certified b y an acceptable certifying agency at the time of
Bid submission . Please use multiple pages of this form to ensure that all tiers of all MWBE subcontractor participation is submitted.