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TCCD SMALL M/WBE SPECIFICATIONS FORM

SMALL M/WBE UTILIZATION

________________________________________    _____________________________

Prime Company Name BID DATE

______________________________________________________    ______________________________________

PROJECT NAMEPROJECT NUMBER

SMALL M/WBE PERCENTAGE ACHIEVED:

TCCD’S SMALL M/WBE PROJECT: _________%

The undersigned bidder agrees to enter into a formal agreement with the Small M/WBE firms for work listed in this schedule, conditioned upon execution of a contract with TCCD.  The willful misrepresentation of facts is grounds for consideration of disqualification and will result in the bid being considered nonresponsive to specifications.

Company Name, Contact Name, Address,

Telephone No.

Small M/WBE

Cert. (*) Agency

Scope of Work

Specify

Tier (**)

Dollar

Amount

(*) Acceptable certifying agencies please specify:(NCTRCA) North Central Texas Regional Certification Agency

(**) Only first and second tier acceptable

THIS FORM MUST BE RECEIVED WITH THE BID DOCUMENTS ON BID OPENING DATE.

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