11/28/16 Council Agenda Packet - Laserfiche WebLink

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Subcontractor Utilization Form City of Eugene | Finance | Purchasing Office 100 W. 10th Ave. Suite 400 | Eugene, OR 97401 Phone (541) 682-5058 | Fax (541) 682-6233 The selected contractor shall complete and submit this form to the City of Eugene within 7 calendar days of award. This information will be used to track utilization of certified D/MWESB firms within City contracting. Return the completed form by e-mail to Eugene.Purchasing@ci.eugene.or.us or by fax or mail to the contact information listed above. Project Name Bid Amount Contract Number (Agency use) Contractor (Company Name) COBID Certification Status*, check all that apply. Status*, check all that apply. Status*, check all that apply. DBE MBE WBE ESBSDVBENone ESB MBE MBE WBE WBE SDVBE Authorized Representative Authorized Representative Title Authorized Representative Title Authorized Representative Title TTTTTTTTTTTTTTTTTTTTTT Authorized Representative Phone Authorized Representative Email Authorized Representative Email Authorized Representative Email By submitting this form, the contractor acknowledges and certifies that this form accurately represents the By submitting this form, the contractor acknowledges and certifies that this form accurately represents the By submitting this form, the contractor acknowledges and certifies that this form accurately represents the intent to utilize the firms listed below, if any, for performance on this project. The contractor certifies that intent to utilize the firms listed below, if any, for performance on this project. The contractor certifies that intent to utilize the firms listed below, if any, for performance on this project. The contractor certifies that FFFFFFFFFFFFFFFFFFFFFF the contractor had direct contact with the firms named regarding participation in this project. If more space the contractor had direct contact with the firms named regarding participation in this project. If more space the contractor had direct contact with the firms named regarding participation in this project. If more space is required, please provide the additional information on a second sheet. is required, please provide the additional information on a second sheet. is required, please provide the additional information on a second sheet. As the Authorized Representative, I certify that the information contained in this form is complete and As the Authorized Representative, I certify that the information contained in this form is complete and As the Authorized Representative, I certify that the information contained in this form is complete and accurate to the best of my knowledge. Yes Date: accurate to the best of my knowledge. accurate to the best of my knowledge. AAAAAAAAAAAAAAAAAAAAAA Name of Subcontractor(s) City State Phone COBID Certification Status* Contract Amount Phone Phone City State RRRRRRRRRRRRRRRRRRRRRR DDDDDDDDDDDDDDDDDDDDDD *Only list COBID certified businesses. Certification for socially and economically disadvantaged businesses in the State of Oregon is available free of charge through the Certification Office for Business Inclusion and Diversity (COBID). Please visit www.oregon4biz.com/How-We-Can-Help/COBID for more information.