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MIAM <br /> COUNTY MIAMI-DADE TRANSIT OFFICE OF CIVIL RIGHTS AND LABOR RELATIONS DBE PROGRAM <br /> DBE CONTRACTOR IDENTIFICATION STATEMENT <br /> 1)Name of DBE Contractor <br /> 2)Year business established <br /> 3)Address and telephone number <br /> 4)DBE Type: Women Black Hispanic Other(specify) <br /> All DBEs must show ownership percentage by gender—Male % Female % <br /> 5)Name of principal officer <br /> 6)Principal type of work <br /> 7)Name of persons involved in management of firm and positions held: <br /> NAME RACE SEX POSITION/TITLE <br /> A. <br /> B. <br /> C. <br /> D. <br /> E. <br /> If additional space is needed,please use another sheet. <br /> 8) For a Corporation or Professional Association (PA): Identify those who own five percent or more of the firm's <br /> stock or five percent or more share of a Professional Association. <br /> NAME RACE SEX OWNERSHIP YEARS OF VOTING <br /> PERCENTAGE OWNERSHIP PERCENTAGE <br /> A. <br /> B. <br /> C. <br /> D. <br /> If additional space is needed,please use another sheet. (Continued on Page 2) <br /> E8/amb <br /> MDT-OCR/LR <br /> DBE FORMS (Rev.6/2009) <br />