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MfIAM}� <br /> COU?Tt MIAMI-DADE TRANSIT OFFICE OF CIVIL RIGHTS AND LABOR RELATIONS DBE PROGRAM <br /> DBE CONTRACTOR IDENTIFICATION STATEMENT <br /> MDT DBE Participation Program <br /> 9)For a Proprietorship,indicate the DBE status and gender of the proprietor: <br /> Black Male Black Female Hispanic Male Hispanic Female <br /> Other Male (Specify) Other Female (Specify) <br /> 10)Does the firm have an 8(a)Certification issued by the Small Business Administration under Section 8(a)of the <br /> Small Business Act as amended (15 U.S.C.637(a)? <br /> NO YES , Certified as an 8(a)Contractor (date) <br /> 11)Date certified as a DBE Cert.No. Expires <br /> 12)The undersigned agrees to provide other relevant information concerning ownership and control if requested <br /> to do so by MDC or its representative. <br /> Signature of Official of DBE Company Title of Official <br /> Date <br /> EB/amb <br /> MDT—OCR/LR <br /> DBE FORMS (Rev.6/2009) <br />