Form 25a326 - Prime Contractor'S Written Dbe Committment Form - Alaska Department Of Transportation Civil Rights Office - Dbe Program - 2000
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1Alaska Department of Transportation Civil Rights Office – DBE Program
PRIME CONTRACTOR’S WRITTEN DBE COMMITTMENT FORM
All firms bidding on Alaska Department of Transportation and Public Facilities (ADOT&PF) projects must
have a written commitment from each DBE firm to be subcontracted. Please complete this form for each
DBE firm and submit to the ADOT&PF Regional Compliance Officer.
If you have any questions, please call (907) 269-0851.
Name of DBE Firm: _______________________________________________________________________
Street Address:
_______________________________________________________________________
Mailing Address:
_______________________________________________________________________
City: ____________________________________________ State: __ Zip Code: ______________________
Telephone Number: _________________________ Fax number: __________________________
Project Name:_________________________________________________ Project Number: ______________
Description of the work that DBE firm will perform:
_____________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________.
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________.
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please provide additional information on a separate sheet of paper.
The dollar amount of participation by the DBE firm: $____________________________________________.
Signatures of Authorized representatives of the Prime Contractor and the DBE firm below represents the
written commitment by the Prime Contractor to subcontract with the DBE firm as described above and a
written commitment by the DBE firm to subcontract for the work described above:
________________________________ _________
_______________________________ __________
Prime Contractor
date
DBE firm
date
__________________________________________
_______________________________________
Name above, typed or printed
Name above, typed or printed
Prime Contractor Firm: __________________________________________________
Address: ______________________________________________________________
______________________________________________________________________
Telephone Number: ______________________________
Fax Number: ___________________________________
Form 25A326 (9/1/2000)
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