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TCCD SMALL M/WBE SPECIFICATIONS FORM

SMALL M/WBE UTILIZATION

Company Name, Contact Name,

Address, Telephone No.

Small M/WBE

Cert. (*) Agency

Scope of Work

Specify

Tier (**)

Dollar

Amount

The bidder further agrees to provide, directly to TCCD upon request, complete and accurate information regarding actual work performed by all Subcontractors, including Small M/WBE arrangements submitted with this bid. The bidder also agrees to allow an audit and/or examination of any books, records, and files held by their company that will substantiate the actual work performed by the Small M/WBE on this contract, by an authorized officer or employee of TCCD. Any willful misrepresentation will be grounds for terminating the contract or debarment from TCCD work for a period of not less than three (3) years and for initiating action under federal, state or local laws concerning false statements.

All Small M/WBE firms MUST BE CERTIFIED BEFORE CONTRACT AWARD.

_____________________________________________________________________

Authorized Signature Company Name

____________________________________________________________________

Title Date

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