DBE PARTICIPATION FOR FEDERAL PROJECTS
EO-380 (11-14)
www dot state pa us
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original ( ) or Revision #________________________________________
letting Date/BID Date: _____________________
(mm/dd/yyyy)
Date:___________________ Project owner:__________________________________________________________________________
CoNtRACt NUMBER
PRojECt
fEDERAl NUMBER
CoUNty
DBE goAl
BID AMoUNt
PRIME CoNtRACtoR
CoNtACt PERSoN
PhoNE NUMBER
cOmPLETE ThiS SEcTiON fOr DbE firm
DBE fIRM
DBE CERtIfICAtE NUMBER
CoNtACt PERSoN
PhoNE NUMBER
totAl AgREEMENt $____________________________
MoBIlIzAtIoN $____________________________
(Include Mobilization)
CREDIt @ 60% $________________________________
(Regular Dearler Only)
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StARtINg DAtE:
CoMPlEtIoN DAtE:
(mm/dd/yyyy)
(mm/dd/yyyy)
ChECk thE APPRoPRIAtE BloCk:
SUBCoNtRACtoR
REgUlAR DEAlER
SERvICE
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MANUfACtURER
CoNSUltANt
othER ________________________________________________
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Identify the North American Industrial Classification System Code(s) that correspond(s) to the work to be performed by the DBE firm.
NAICS Code:________________________________________
Description of work for all item numbers; including partial items:__________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I am a DBE certified by the Pennsylvania Unified Certification Program (PA UCP). I hereby certify that as a DBE, I quoted the above
price and type of work.
Signature of DBE:________________________________________________________________
Date: _____________________
(Signature and Title of Company Official)
(mm/dd/yyyy)
I hereby certify, on behalf of, and intending to bind, the Bidder, that the information contained herein is true and correct to the best of my
knowledge, information and belief.
Signature of PRIME:______________________________________________________________
Date: _____________________
(Signature and Title of Company Official)
(mm/dd/yyyy)
PENNDOT USE ONLY
Approved
Conditional Approval (Prequalification only)
Disapproved
Condition: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________ By:_________________________________ Date: ______________
Note: Complete one form for each DBE on the project