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MINORITY AND WOMEN BUSINESS ENTERPRISES <br /> PARTICIPATION REPORT <br /> Project No. Project Title: Date: <br /> Institution or Agency Principal Representative <br /> MBE: Yes ❑ WBE: Yes ❑ <br /> Architect/Engineer/Consultant or Contractor No ❑ No ❑ <br /> Total Contract Amount:$ <br /> Name and Address of M/WBE MBE WBE Type of Work <br /> Subcontractors and/or Suppliers and/or Contract Contract <br /> Self-Performed Work by M/WBE Primes` Amounts Amounts <br /> `Indicate ethnicity based on Paragraph 111. A. above. <br /> Total MBE Contracts: $ <br /> Total WBE Contracts: $ <br /> Total MBE%: <br /> Total WBE%: <br /> SIGNATURES: <br /> Principal Representative Architect/Engineer/Consultant or Contractor <br /> Authorized Representative Authorized Representative <br /> MBEREPORT FORM <br /> (WO02) <br /> Page 2of2 <br />