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<br />Project No. <br /> <br />ff' <br /> <br />. <br /> <br />MINORITY AND WOMEN BUSINESS ENTERPRISES <br />PARTICIPATION REPORT <br /> <br />Project Title: <br /> <br />Date: <br /> <br />Institution or Agency <br /> <br />Principal Representative <br /> <br />MBE: Yes 0 WBE: Yes 0 <br />No 0 No 0 <br /> <br />Architect/Engineer/Consultant or Contractor <br />Total Contract Amount: $ <br /> <br />Name and Address of MIWBE MBE WBE Type of Work <br />Subcontractors and/or Suppliers and/or Contract Contract <br />Self-Performed Work by MIWBE Primes* Amounts Amounts <br /> <br />*Indicate ethnicity based on Paragraph III. A. above. <br />Total MBE Contracts: $ <br />Total WBE Contracts: $ <br />Total MBE %: <br />Total WBE %: <br /> <br />SIGNATURES: <br /> <br />Principal Representative <br /> <br /> <br />MWBE-1 <br />(09/2004). <br /> <br />Architect/Engineer/Consultant or Contractor <br /> <br />Authorized Representative <br />