Note: See next page for continuation of Prices

Total Base Bid Price (In Words)

Total Alternate Bid Price (In Words)

DISADVANTAGED BUSINESS ENTERPRISE (DBE) PARTICIPATION FORM

1. 
   The Airport Authority has set a goal of seventeen percent (17%) for participation by Disadvantaged Business Enterprises (DBE) for this contract.
   
2. 
   List the percentage level of DBE Participation your Business Proposes for this contract: %
   
3. 
   Describe, in detail, the responsibilities of each DBE participant (attach additional sheets, if necessary) (To be counted towards the DBE goal, a firm must be certified by the due date on the cover of this document.)
   

DBE Name: % of Total Contract:

Address:

Owners/Partners, Principals Name(s):

Detailed Description of Responsibilities:

Is the business certified as a DBE by an agency participating in the Michigan Unified Certification Program (MUCP)? _____ YES _____ NO. Proof of certification must be submitted with this form.

DBE Name: % of Total Contract:

Address:

Owners/Partners, Principals Name(s): Phone #:

Detailed Description of Responsibilities:

Is the business certified as a DBE by an agency participating in the Michigan Unified Certification Program (MUCP)? _____ YES _____ NO. Proof of certification must be submitted with this form.

• 
  The support (financial, technical, management, training, etc.) provided by the Bidder to each DBE partner.
  
• 
  A copy of the documents that contain the proposed legal relationship between the Bidder and each DBE participant (if applicable).
  
• 
  Provide a resume for the principal(s) of the DBE firms identified above.
  

For assistance, or for more information on the Airport Authority’s DBE Program or the Michigan Unified Certification Program (MUCP), contact Lori Ballard, Business Diversity Manager, at Lori.Ballard@wcaa.us or (734) 247-7011.

VERIFICATION OF MINIMUM QUALIFICATIONS FORM
Failure to complete this form and/or provide the information requested will result in your Bid being deemed nonresponsive and rejected without any further evaluation.
Describe how you meet or exceed the Minimum Qualifications of the RFB.
a) Provide at least three (3) projects that your Business has successfully managed and successfully completed as the Prime Contractor within the last seven (7) years, as required in the minimum qualifications, that included at least two of the following: (i) 150,000 cubic yards of unclassified excavation; (ii) 7,000 tons of bituminous pavement; and (iii) 15,000 square yards of Portland Cement Concrete (PCC) pavement. The above work could have been self performed or performed by a first tier subcontractor. Attach additional sheets if necessary.
1. Client/Owner: ___________________________________________________________
Contact Name: __________________________ Title: ____________________________
Phone Number: ________________________ Date Project Completed: _____________
Self Performed: Y or N If No, provide subcontractor:
Describe Project Scope: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Client/Owner: ___________________________________________________________

2. 
   Provide at least five (5) terminal navigational aid facility installations, that your business or a subcontractor that will be assigned to the contract resulting from this RFB, successfully managed and successfully completed within the last seven (7) years:
   

1. Client/Owner: ___________________________________________________________

2. 
   List of the Bidder’s staff who is a Project Manager(s) with a minimum of seven (7) years of experience who will be assigned to the project outlined in this RFB, as required in the minimum qualifications. Duplicate below lines if required. Attach resume for each staff listed.
   

Name: __________________________ Title: ____________________________

2. 
   List of the Bidder’s staff who is a Site Superintendent(s) with a minimum of ten (10) years of experience who will be assigned to the project outlined in this RFB, as required in the minimum qualifications. Duplicate below lines if required. Attach resume for each staff listed.
   

Name: __________________________ Title: ____________________________

2. 
   List of the Bidder’s staff, or staff of a subcontractor that will be assigned to the contract resulting from this RFB, who has a minimum of three (3) years of experience installing NAVIAD facility installations for terminal navigational aid facilities, as required in the minimum qualifications. Duplicate below lines if required. Attach resume for each staff listed.
   

Name: __________________________ Title: ____________________________

SECTION 7 – OTHER FORMS

PRINCIPAL OFFICE ADDRESS

TELEPHONE NUMBER
FORM OF OWNERSHIP (Check One)

Corporation ( ) LLC ( ) Joint Venture ( )

State of Incorporation/Registration Date of Incorporation/Registration

Partnership ( ) If Partnership, select one of the following: Limited ( ) or General ( )

Individual ( )

LIST OF PARTNERS, PRINCIPALS, CORPORATE OFFICERS OR OWNERS

LIST OF CORPORATE DIRECTORS

Principal Business Affiliation

Name Other Than Proposer Directorship












ADDITIONAL INFORMATION REQUIRED BY THE AUTHORITY
LIST OF PRINCIPAL STOCKHOLDERS (i.e., those holding 5% or more of the outstanding stock)

Name Address








FINANCIAL DISCLOSURE/CONFLICTS OF INTEREST:  Identify any contract(s), including any contract involving an employment or consulting relationship, which the firm, or its partners, principals, corporate officers or owners currently has with the Wayne County Airport Authority, or with any of its board members or officers. 





LATEST CREDIT RATING (Specify if other than Dun and Bradstreet)

I hereby certify that the foregoing business information is true, correct and complete to the best of (my/our) knowledge and belief:

(Name of Company)

(Signature) Date

(Title)
By

(Signature) Date

(Title)

The undersigned has viewed, purchased or downloaded all project requirements, drawings and specifications issued as part of this RFB and comprehends the scope of the work, schedule and services required to complete the project.

Firm: _______________________________

Print Name________________________________ Title:___________________________________

(Authorized Representative)

Signature:______________________________ Date:__________________________________