Dbe Description Of Work And Field Monitoring Report (Exhibit A) Form
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1
2Minnesota Department of Transportation
Office of Civil Rights
DBE Description of Work
And Field Monitoring Report (Exhibit A)
A contract will not be awarded to the Prime Contractor unless this form is submitted with a signed subcontract, purchase order or affidavit for each
DBE participating in the contract. This form is complete when the DBE subcontractor has filled in all of the applicable information in sections A
and B and signs in section C.
PLEASE PRINT CLEARLY OR TYPE.
Section (A): (All DBE Subcontractors, including Trucking firms must complete this Section.)
MUST BE COMPLETED BY THE DBE PRINCIPAL
Letting Date: ____________________________________
State Project Number: _____________________
Prime Contractor:
Phone #:
DBE Subcontractor:
Phone #:
DBE Principal Name:
Total Subcontract $: _
DBE Participation Claimed:
Percent _________%
Amount $ ________________________
1.
Did you bid and sign a subcontract agreement with the above-named prime contractor? ______________________________
2.
Are the items, quantities, and prices listed on the subcontract agreement or affidavit correct? ____________________________
3.
List the line items to be performed: _______________________________________________________________________
________________________________________________________________________________________________________
4.
Are there any other agreements not addressed in the subcontract? If yes, please explain: _____________________________
________________________________________________________________________________________________________
5.
If equipment to be used is other than what is listed in your DBE certification file please answer the following:
a.
Will the renting or leasing include any of the following: (Attach a copy of the lease or rental agreement(s).
Equipment __________ Insurance ___________ Operator ___________ or Maintenance ___________
b.
Lessor’s name: ___________________________________________________________________________________
Amount to be paid: _____________________ Number of days to be used: ____________________
6.
Will there be any other firm(s) providing work listed in your (DBE) subcontract?
If yes, answer the following: Firm’s Name: ___________________________ $ amount of the work: __________________
2.
What is the name of the person supervising your work on this project? ___________________________________________
Is this your employee? ____________________
8.
How many people will you be employing on this project? ____________ Minorities: ____________ Females: ___________
9.
Total dollar amount of materials to be supplied? ____________________________________________________________
10. Who are you purchasing the materials from? _______________________________________________________________
1.
Please submit Purchase Agreement and/or Purchase Order from manufacturer(s) or primary material supplier(s).
NOTE: This Exhibit ‘A’ will not be approved without the Purchase Agreement/Purchase Order.
2.
Please list all subcontracts that your firm will be performing during the current construction season including non-DBE work:
(Attach additional sheet if necessary.)
Project Number
Prime Contractor
Project Location
# of Working Days
1.
2.
3.
Mn/DOT OCR
8/2010
DBE Page 1
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