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4111\ <br /> Disadvantaged Business Enterprise (DBE) <br /> 71 Washington State <br /> Department of Transportation Written Confirmation Document <br /> See Contract Provisions: DBE Document Submittal Requirements <br /> Disadvantaged Business Enterprise Condition of Award Participation <br /> I THIS FORM SHALL ONLY BE SUBMITTED TO A DBE THAT IS LISTED ON THE CONTRACTOR'S <br /> DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION CERTIFICATION. <br /> ITHE CONTRACTOR SHALL COMPLETE PART A PRIOR TO SENDING TO THE DBE. <br /> IPART A: To be completed by the bidder <br /> The entries below shall be consistent with what is shown on the Bidder's Disadvantaged Business Enterprise <br /> IUtilization Certification. Failure to do so will result in Bid rejection. <br /> Contract Title: <br /> Bidder's Business Name: <br /> IDBE's Business Name: <br /> Description of DBE's Work: <br /> IAmount to be Applied Towards DBE Goal: <br /> I Amount to be Subcontracted to DBE*: <br /> *Optional Field <br /> I, PART B: To be completed by the Disadvantaged Business Enterprise <br /> As an authorized representative of the Disadvantaged Business Enterprise, I confirm that we have been <br /> I contacted by the Bidder with regard to the referenced project for the purpose of performing the Work described <br /> above. If the Bidder is awarded the Contract, we will enter into an agreement with the Bidder to participate <br /> in the project consistent with the information provided in the Bidder's Disadvantaged Business Enterprise <br /> IUtilization Certification. <br /> Name (printed): <br /> Signature: <br /> Title: <br /> IAddress: Date: <br /> I <br /> I <br /> I DOT Form 422-031 <br /> Revised 07/2016 <br />