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I <br /> Washington State Disadvantaged Business <br /> Ill 4/ Department of Transportation <br /> Enterprise Utilization Certification <br /> ITo be eligible for Award of this Contract the Bidder shall fill out and submit, as a supplement to its sealed Bid Proposal, <br /> a Disadvantaged Business Enterprise (DBE) Utilization Certification.The Contracting Agency shall consider as non- <br /> responsive and shall reject any Bid Proposal that does not contain a DBE Utilization Certification which properly <br /> demonstrates that the Bidder will meet the DBE participation requirements in one of the manners provided for in the <br /> Iproposed Contract. Refer to the instructions on Page 2 when filling out this form or the Bid may be rejected.An <br /> example form has been provided on Page 3.The successful Bidder's DBE Utilization Certification shall be deemed a <br /> part of the resulting Contract. <br /> IBox 1: Always Active Services LLB., certifies that the DBE firms listed below have been contacted <br /> regarding participation on this project. If this Bidder is successful on this project and is awarded the Contract, it shall <br /> assure that subcontracts or supply agreements are executed with named DBEs. (If necessary, use additional sheets.) <br /> IBox 2: Fleming Bicycle Corridor <br /> Column 1 Column 2 Column 3 Column 4 Column 5 <br /> Name of DBE Project Role Description of Work Dollar Amount Dollar Amount <br /> 11 (See instructions) (See instructions) (See instructions) Subcontracted to DBE to be Applied <br /> Towards Goal <br /> (See instructions) (See instructions) <br /> I Always Active Permanent Signing, / cod <br /> Services LLC Prime Contractor SPCC Plan and Inspection,Trucking N/A � <br /> (4 tic)ti (aroup 6((Mil(J AC( ifGI-4,c- CClii YdI ,f( 9 4S 17 0r) 0 4iJ / duo <br /> 1 <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I f�11 <br /> Disadvantaged Business Enterprise 1 e r k S 4'T4( Total DBE Commitment Dollar Amount U 1 100 0 <br /> Condition of Award Contract Goal Box 380,t4s6,.Li( aj - Box 4 <br /> I5 n By checking Box 5 the Bidder is stating that their attempts to solicit sufficient DBE participation to meet <br /> the COA Contract goal has been unsuccessful and good faith effort will be submitted in accordance with <br /> I <br /> Section 1-02.9 of the Contract <br /> Page 11 of 30 <br /> DOT Form 272-056 C <br /> Revised 03/2018 <br /> .-...,;,-LmA 1-^ R,,;l.icre Wvrh=nrc of WA_ Tnr rnr Heal,, r'nnr3itinn.c A(TrPPmPnt. SPP www.hxwa.com - Always Verify Scale <br />