/ Subcontractor Non-DBE Participation Form

A separate Non-DBE Information Form must be completed for each Non-DBE firm that will be working or otherwise participating on the Prime contract by operating all or part of the project or by providing goods or services as a Prime and/or subcontractor (including suppliers). Duplicate this form as needed.

All fields on this form must be completed; no fields should be left blank. If appropriate, complete a field with “not applicable” or “N/A”. Ensuring accurate completion of this Non-DBE Participation Form is the responsibility of the prospective Prime Contractor. This form must be submitted as part of the complete bid submission. Note: Both the Prime Contractor and Non-DBE firm’s authorized representative must sign this form.

For further guidance on the completion of this form, carefully review the attached instructions.

A.  Non-DBE’s Contact Information

(1) Project Title / (2) Solicitation Control Number / (3) Prime Contractor Name

B. Non- DBE Participation Plan

(1) Name of Non-DBE firm / (2) Non-DBE Contact Person Name/Title / (3) Non-DBE Contact Phone #
(4) Name of the business the Non-DBE firm will have a
direct contract /working relationship.
/ (5) Explain any association the Non-DBE firm has with the Prime Contractor.
(6) Description of work to be performed by the Non-DBE firm
(7) Anticipated Start Date for Non-DBE firm
/ / / (8) Total Dollar Value of Non-DBE firm participation
$

C.  Non-DBE’s Business Information

(1) Description of Primary Business / (2) Federal Tax ID
(3) Incorporation Date
/ / / (4) Ownership Date
/ /
(5) Type of Firm
q Sole Proprietorship q Corporation q Partnership
q Joint Venture q Limited Liability Partnership (LLP) q Limited Liability Corporation (LLC)
q Other (Describe) ______
(6) List all applicable NAICS Codes for work the Non-DBE is certified and/or qualified to perform.
NAICS Code
______
______
______/ Related Description NAICS Code Related Description
______
______
______

D. Certification and Signature

Under penalty of perjury, I certify that:

(1) I am authorized to execute this form on behalf of my firm;

(2) I have conducted reasonable due diligence in collecting the information to be submitted on or with this form;

(3) I understand that this form contains material statements relied upon by the Airport Authority as a part of their decision-making process, and, based on my knowledge, the foregoing form does not contain any untrue information or omit any material fact necessary to make the information contained herein true and complete;

(4) I have read and understand the rules, regulations, and policies applicable to the Airport Authority’s DBE program;

(5) I, and the organization I represent, are in compliance with the rules, regulations, and policies applicable to the Airport Authority’s DBE program; and

(6) I understand that if the Airport Authority determines that any information provided on this form, or any other document submitted to the Airport Authority in connection with the subject solicitation, is intentionally false or misleading, the Airport Authority may pursue any and all remedies at law or in equity, including without limitation termination of any and all contracts with my firm, designating my firm as non-responsible on future bid opportunities, debarment of my firm from doing business with the Airport Authority, as well as referral of my firm to the appropriate certifying and law enforcement agency(ies).

Printed Name and Title of Prime Contractor Authorized Representative / Signature of Prime Contractor Authorized Representative / Date
Printed Name and Title of Non-DBE Firm Authorized Representative / Signature of Non-DBE Firm Authorized Representative / Date

(Note: A facsimile/copy of the executed signature page may be accepted at bid deadline. However, the original executed signature page must be provided to the Airport Authority within two (2) business days after bid deadline.)

Revised 12/12/2011 Non-DBE Participation Form

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