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I <br /> ' V"7/ Washington State <br /> ransportation Disadvantaged Business <br /> Department of TEnterprise Utilization Certification <br /> To be eligible for Award of this Contract the Bidder shall fill out and submit, as a supplement to its sealed Bid Proposal, <br /> I 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 /> I proposed 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 /> Box 1: 7?,;, /1.41,1 tic • certifies that the DBE firms listed below have been contacted <br /> I regarding participatron 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 /> Lj21-cQ— <br /> Box 2: 1 f 7 _2-37k/5.-"GA'A,-. fS.., <br /> IColumn 1 Column 2 Column 3 Column 4 Column 5 <br /> Name of DBE Project Role Description of Work Amount Amount to be <br /> I (See instructions) (See instructions) (See instructions) Subcontracted Applied Towards <br /> to DBE Goal <br /> (See instructions) (See instructions) <br /> µ:5b„,47 per/k.."—$„fpr S,S..s «'/y 41 bay' o..dy <br /> I <br /> ft:7(44 f - GL G 501194'4V (-A.20-...r--7.f.724,,,/) 26 so PO 4(/5;oo b <br /> P4c of 9 389 <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> IDisadvantaged Business Enterprise 8y Total DBE Commitment 2.912 <br /> Condition of Award Contract Goal Box 3 Box 4 <br /> I5(I By checking Box 5 the Bidder is stating that their attempts to solicit sufficient DBE participation to meet <br /> the OA Contract goal has been unsuccessful and good faith effort will be submitted in accordance with <br /> Section 1-02.9 of the Contract <br /> IoDOT Form 272-056 <br /> i 165 Disdastfgel3hb'siness Enterprise Utilization Certification <br /> ded to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com-Always Verify Scale <br />