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MIAMI• <br /> COUNTY MIAMI-DADE TRANSIT OFFICE OF CIVIL RIGHTS AND LABOR RELATIONS DBE PROGRAM <br /> PRIME AND SUBCONTRACTORS INFORMATION FORM <br /> INSTRUCTIONS:To be completed by the prime and by all subcontractors that submitted a bid on the project. <br /> Bid Description: Bid No. <br /> Percentage of DBE Goal <br /> BIDDER INFORMATION <br /> Firm Name F.E.I.N.* <br /> Street Suite No. <br /> City State Zip Code <br /> Prime Bidder?Yes No If No,enter name of Prime <br /> Year Founded Annual Gross Receipts:Under$500k Over$500k <br /> Phone No. FAX No. Email <br /> SPECIALTY <br /> USE APPROPRIATE TWO-DIGITS SBA STANDARD INDUSTRIAL CLASSIFICATION CODE(SIC): <br /> Construction: Building--SIC 15 Heavy--SIC 16_Specialty Trades--SIC 87 <br /> Professional Services(Architectural,Engineering,Accounting,etc.) SIC 87 <br /> Goods,Equipment and Non-professional Services <br /> MIAMI-DADE COUNTY CERTIFIED DBE: <br /> Certificate Expiration Date: / / Ethnicity Gender <br /> AFFIDAVIT <br /> I certify that I am an authorized representative of above named firm. <br /> Signature Name Title Date <br /> 4600 <br /> .,.r..,� ets i ii*. ::M AWSU Pjecbid wa► kd th <btddi t Y _ am=N O <br /> .». .. ...._ <br /> . 1 <br /> EB/amb <br /> MDT-OCR/LR <br /> DBE FORMS (Rev.6/2009) <br />