HomeMy Public PortalAboutMSD Professional Service Form A-1DESIGN PROFESSIONAL SERVICES MSD FORM A-1
MBE / WBE UTILIZATION FORM
Prime Consultant (Proposer):______________________________________________________________
RFP / RFQ Name: ___________________________________________________________________
RFP / RFQ Number: _________________________________________________________________
MBE / WBE Utilization Plan for MBE and WBE Subconsultants:
Note: Please select MBE or WBE for each sub listed. You must choose either MBE or WBE for Firms who qualify M/WBE certifications.
1) MBE / WBE Firm Name: __________________________ Certified By: ________ Ethnicity:________
Address: __________________________ City: _______________ State :________ Zip Code :________
Email: _____________________________ Phone:__________________ Contact Name:_____________
Subconsultant to (check one): Prime Another Subconsultant (Name:___________________________)
Description of Scope of Services Proposed Participation % ________________________
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________
2) MBE / WBE Firm Name: __________________________ Certified By: ________ Ethnicity:________
Firm Address: __________________________ City: __________ State :________ Zip Code :________
Email: _____________________________ Phone:__________________ Contact Name:_____________
Subconsultant to (check one): Prime Another Subconsultant (Name:___________________________)
Description of Scope of Services Proposed Participation % ________________________
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________
3) MBE / WBE Firm Name: __________________________ Certified By: ________ Ethnicity:________
Firm Address: __________________________ City: __________ State :________ Zip Code :________
Email: _____________________________ Phone:__________________ Contact Name:_____________
Subconsultant to (check one): Prime Another Subconsultant (Name:__________________________)
Description of Scope of Services Proposed Participation % ________________________
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________
The utilization plan provided herein will be used for purposes of evaluating goal achievement. I certify to meet, exceed
or provide GFE to meet Diversity goal Program requirements. Copy this sheet if additional space is needed to list
more MBE’s or WBE’s.
_____________________________________ ________________________________
Consultant Authorized Signature Date