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SMALL M/WBE DEVELOPMENT QUESTIONNAIRE

[Please circle appropriate tier]

NOTE: Vendors are to complete this form along with a copy of the

Contractor and 1st Tier, 2nd Tier, and/or 3rd Tier Subcontractor/Supplier Participation Forms

and return it in a separate envelope to:

Tarrant County College District

1500 Houston Street

Fort Worth, Texas 76102-6599

Firm Name:__________________________________________________________

Firm Address:__________________________________________________________

__________________________________________________________

Telephone:_________________________________

Fax Number:_________________________________

E-mail Address: ______________________________

CONTACT PERSON’S NAME AND PHONE NO. _____________________________________

SIGNATURE OF FIRM’S AUTHORIZED OFFICIAL: __________________________________

NAME AND TITLE (Type or Print): _________________________________________________

COMPANY MAJORITY OWNERSHIP (Check one in each column)

ETHNICITYGENDERLOCATION

______African American (AA)_____  Male____  Fort Worth (Ft. W)

______Asian Pacific American (APA)_____  Female____  Texas (T)

______Caucasian (C) ____  Out of State (OS)

         Specify State ____

______Hispanic American (HA)

____  Publicly Owned (PO)

______Native American (NA)

______Other (OT) Specify ____________________

BUSINESS CLASSIFICATION

_____SB Small Business _____WBE Women Owned Business Enterprise

_____MBE Minority Business Enterprise

Please provide information regarding certifying agency (if any)

Name of AgencyCertificate NumberExpiration Date

_______________________________________________________________________________

______________________________________________________________________________

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