Affirmative Action Plan Format Page 32
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43Attachment IIIa
For Design/Build (multi-phase contract) Only
Small Contractor and Minority Business Enterprise Goals and/or
“Good Faith Effort” Contractor Participation
Date Submitted: _____________ Project Number: ____________ Project Name: ___________________________
Project Start Date: __________
Estimated Project Completion Date: ____________
Total Project Value is $ _____________. Project has SBE requirement of ________ %, which includes MBE
requirement of ________%; OR, Project requires only “good faith effort” for MBE contractors ___________.
The head of the company has read this Attachment IIIa and confirms that its information is true and correct to the best
of his or her knowledge and belief. The general contractor pledges its best good faith efforts to achieve the set-aside
goals outlined in this Attachment IIIa. Furthermore, the general contractor is aware of its continuing obligation to
remain vigilant in filing an Attachment IIIa on a monthly bases, unless new developments require an additional filing
of an amended Attachment IIIa prior to the monthly filing due date.
Signature of the Head of the Company/Title
Date
Signature of the AA/EOE Officer
Date
on the project.
Please identify MBE/WBE/DISBE subcontractors/vendors who will participate
A.
Company Name
Address
DAS Certification
DAS
Contract Value
Type
Certification
(MBE/WBE/DisBE)
Expiration Date
= ______% of Project Value
B. Please identify SBE contractors/vendors who will participate on the project.
Company Name
Address
DAS Certification
DAS Certification
Contract Value
Type
Expiration Date
(SBE)
= ______% of Project Value
= ______% of Project Value
DisBE/WBE/MBE
Total SBE/
contract value =
Please use additional sheets if necessary
Page 32 of 43
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