Dbe Mbe Wbe Replacement Request Form - State Of North Carolina Department Of Transportation
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2DBE MBE WBE REPLACEMENT REQUEST FORM
The North Carolina Department of Transportation (NCDOT) is committed to the participation of
Disadvantaged, Minority and Woman Business Enterprises (DBE/MBE/WBE), in contracting opportunities in
accordance with 49 Code of Federal Regulations (CFR).
In accordance with the Special Provisions, the Contractor shall not terminate a committed DBE/MBE/WBE
subcontractor for convenience or perform the work with its own forces or those of an affiliate.
Reasonable
methods to resolve performance disputes must be applied. The contractor shall follow the attached Instructions
for Submittal of Replacement. Replacement of a DBE/MBE/WBE without written approval from NCDOT is a
violation of contract provisions and may result in the Contractor being disqualified from bidding for a period of
up to 6 months.
Contract Number: _________________________________________________________________________
DBE/MBE/WBE being replaced: _____________________________________________________________
Explanation for Replacement: _______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Subcontract Amount: ______________________________________________________________________
Amount of Subcontract Remaining: __________________________________________________________
Line Items: _______________________________________________________________________________
If a committed DBE/MBE/WBE subcontractor is terminated for good cause as specified in the Special
Provisions the Contractor will make a good faith effort to find another DBE/MBE/WBE subcontractor to
substitute for the terminated DBE/MBE/WBE. These good faith efforts shall be directed at finding another
DBE/MBE/WBE to perform at least the same amount of work under the contract as DBE/MBE/WBE that was
terminated, to the extent needed to meet the contract goal established for the project
Replacement DBE/MBE/WBE: __________________________________________________________
Amount of Subcontract: _________________________________________________________________
Line Items: _____________________________________________________________________________
New Committed DBE/MBE/WBE Signature:
Date:
By signing this document, the Contractor, DBE/MBE/WBE and the NCDOT Contract Administrator
acknowledges that the 5 days to respond was given, and concurs with the process of replacing the named
DBE/MBE/WBE subcontractor.
______________________________________________________________________________________
Original DBE/MBE/WBE Signature
Date
______________________________________________________________________________________
Prime Contractor Signature
Date
______________________________________________________________________________________
NCDOT Contract Administrator
Date
Upon Completion Send to: State Contractor Utilization Engineer
State Construction Engineer
Version: 10-2015
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