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					WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 1 of 13

SPECIAL CONDITIONS OF BID TABLE OF CONTENTS
SECTION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. SUBJECT SCOPE CONTRACT TERM BIDDER QUALIFICATIONS SPECIFICATIONS DELIVERY REVISIONS METHOD OF BID / AWARD BID RESPONSE REQUIREMENTS PROOFS SAMPLES MINORITY BUSINESS PARTICIPATION SUBCONTRACTING OR THIRD PARTY PAYMENTS FIRM PRICES INVOICING REQUIREMENTS CONTRACT CANCELLATION CERTIFICATION FOR COLLECTION OF SALES AND USE TAX DISPOSTION OF UNUSED MATERIALS PRODUCTION TIME ALLOWANCES PROPERTY NEW TECHNOLOGY

Attachment A - VENDOR INFORMATION sheet Attachment B - REFERENCES sheet Attachment C - WisDOT MBE PROGRAM AWARENESS, COMPLIANCE & ACTION PLAN

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 2 of 13

1.

SCOPE
The Wisconsin Department of Transportation (WisDOT or DOT), through its Purchasing Unit (Purchasing), requests bids to establish a contract for printing of form T055, Wisconsin Certificate of Title using security paper, security ink, and special numbering. The attached Standard Terms and Conditions shall govern this bid unless specifically modified in the Special Conditions of Bid. Conditions of bid that include the word "must" or "shall,” describe a mandatory requirement. All specifications are defined as mandatory minimum requirements unless otherwise stated. If no bidder is able to comply with a given specification or condition of bid, Purchasing reserves the right to delete that specification or condition of bid. Failure to meet a mandatory requirement shall disqualify your bid. If you have questions regarding the specifications, or special conditions of bid, please contact the purchasing agent shown on the bid cover sheet as soon as possible, but no later than 5 working days prior to the bid opening date in writing only. If the answer requires written notification to other bidders, purchasing will issue an official addendum. Any correspondence, documents, price lists, etc. to support your bid, must include the bid number and be sent to Purchasing, 4802 Sheboygan Ave. Rm. 751, P O Box 7396, Madison, WI 53707-7396 to be acknowledged. Retain a copy of these Special Conditions of Bid for your files. Should you receive an award, these Special Conditions of Bid become your contract terms and conditions. Questions regarding this bid shall be submitted in writing and answered by the following: Mary Hensler at e-mail mary.hensler@dot.state.wi.us

2.

CONTRACT TERM
June 1, 2007, or date of award, through December 31, 2008, or two years after date of award, with three (3) one-year renewal options. WisDOT reserves the right to extend beyond the contract period if deemed to be in the best interest of WisDOT.

3.

BIDDER QUALIFICATIONS
To be eligible for a contract award, you must be qualified and able to provide the following. 3.1 The successful bidder must produce (in the bidder‟s own plant) all printing of the T055, Certificate of Title. Successful bidder will be held responsible for all work done by subcontractors. Bidders will be required to indicate what type of work they are subletting and to whom. The bidder will be required to submit the proposed sub-contractor‟s equipment list that will be evaluated as part of the bidders total bid response. Failure to submit required information within seven (7) calendar days after WisDOT makes a request may be cause for rejection of a vendor‟s bid. Award will not be made to a broker Bidder must supply references of three firms to which similar products / service have been provided during the past three years to a comparable sized institution or company. If contacted, all of those references must verify that a high level of satisfaction was provided. Use Attachment B to list references. Contractor should be able to report on a quarterly basis all products purchased against this contract.

3.2 3.3

3.4

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 3 of 13

3.5

A performance bond in the amount of $250,000 signed by a Wisconsin resident agent of the bonding company may be required at the expense of the printer before the printing order will be issued. The bond is to assure quality printing and attention to the attached specifications and schedules.

4

SPECIFICATIONS
See attached PRINT SPECIFICATIONS for the minimum acceptable specifications for products desired. Bid specifications may not be revised without an official written addendum issued by Purchasing.

5.

DELIVERY
Departmental personnel will issue contract release orders to the successful bidder during the contract term. Orders are to be delivered to locations as indicated on the purchase order. Delivery must be F.O.B. Destination Door Delivery with shipping charges, etc. included in the bid price. Bidders are to state on the Bid Cover Page specified in Section 18 of these special conditions of bid.

6.

REVISIONS
WIDOT may require revisions with each production run. Prescribed revisions will typically involve line and copy changes to entire sections of the form. NOTE: These forms require a custom pantograph to be created and positioned within the Wisconsin Certificate of Title as described in the specifications. WIDOT must approve the pantograph prior to production.

7.

METHOD OF BID / AWARD
Bidders are requested to bid per thousand forms. WIDOT will guarantee an order will be placed for the minimum of the quantity range indicated and the order will be no larger than the maximum of the quantity range indicated. Failure to bid as requested may result in disqualification of your bid. Award(s) shall be made on the basis of the lowest total cost of line three (3) from a responsive, responsible bidder who meets specifications. The first order will be for 1,000,000 Wisconsin Certificate of Title forms.

8.

BID RESPONSE REQUIREMENTS
In order for your bid to be considered, the following information must be provided. Submit one copy (unless stated otherwise) of your bid by the due date and time listed on the bid cover page. Include: 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Bid Cover (Signature) Page Addendum Cover (Signature) Page(s) Bidder Response Sheet Bid Price Sheet Vendor Information Sheet, Attachment A References Sheet, Attachment B MBE Program Awareness, Compliance & Action Plan, Attachment C

Failure to provide these forms/information with your bid submittal may disqualify your bid. Bids may not be submitted via facsimile. It is the bidder‟s responsibility to ensure that all documents are readable and completely received at the DOT Purchasing Office by the due date and time. Because of increased building security, access to the WisDOT Purchasing Office is restricted and may cause delay if hand delivering your bid. Allow ample time for security clearance to room 751.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 4 of 13

9.

PROOFS
Refer to attached Print Specifications for detailed proof specifications.

10.

SAMPLES
Samples of similar work may be required (jobs requiring security paper and pantographs). When samples are requested, they must be delivered to Purchasing within seven (7) calendar days of that request. Failure to provide samples as requested may disqualify your bid.

11.

MINORITY BUSINESS PARTICIPATION
The Wisconsin Department of Transportation is committed to the promotion of minority businesses in the State‟s purchasing program. Authority for this program is found in Wisconsin Statutes 15.107(2), 16.75(3m), and 16.755. Bidders are strongly urged to use due diligence to further this policy by setting up subcontracts to statecertified Minority Business Enterprises (MBE) and/or by using such enterprises to provide goods and services incidental to this contract (second-tier suppliers), with a goal of awarding 5% of the contract cost to such enterprises. An MBE means a business certified, or certifiable, by the Wisconsin Department of Commerce under Statute 560.036(2). Bidders must submit the attached WisDOT MBE Program Awareness, Compliance & Action Plan-Attachment C indicating their proposed utilization of state-certified minority businesses for this contract. Contact the State‟s Minority Business Director for assistance in locating certified firms at (608) 267-7806 or the WisDOT Minority Business Program Specialist at 608-267-2886. A listing of State of Wisconsin certified minority businesses, as well as the services and commodities they provide, is on the Statecertified MBE web site: http://www.doa.state.wi.us/deo/mbe/minority_search.asp Quarterly reports, as agreed, are requested to be submitted to the Department of Transportation, Purchasing Unit, itemizing the deliveries and cost of items or services provided by certified firms. Reports should state the costs for the previous contract quarter, as agreed. The department reserves the right to verify with listed firms their involvement as subcontractors or second-tier suppliers.

12.

SUBCONTRACTING OR THIRD PARTY PAYMENTS
All subcontracting shall be pre-approved by WisDOT. Subcontractors must abide by all terms and conditions of the contract. The prime contractor shall be responsible for all subcontractor(s) work and payment. The WisDOT will not pay any subcontractor or third parties directly.

13.

FIRM PRICES
WIDOT intends that pricing shall remain firm for the contract period. Award of this contract is based on competitive pricing. Increases in pricing will not be considered unless justified with supported written documentation substantiating your inability to continue without monetary damage. A determination would be made at that time whether to accept the price increases and continue the contract for the time remaining. Any rate increase must be received in writing and approved by the Wisconsin Department of Transportation 60 days before becoming effective.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 5 of 13

14.

INVOICING REQUIREMENTS
Invoices/Purchase Order: WisDOT must meet a statutory mandate to pay or reject invoices within 30 days of receipt by WISDOT. Before payment is made, it also must verify that all invoiced charges are correct as per this contract. Only properly submitted invoices shall be officially received for payment. Thus, your prompt payment requires that your invoices be clear and complete in conformity with the instructions below. All invoices must be itemized showing: a. b. c. purchase order number vendor name remit to address d. e. complete product description as stated on your bid. prices per the contract

The original invoice and two copies must be sent to the bill-to address shown on the Purchase Order.

15.

CONTRACT CANCELLATION
This Contract may be terminated by either party under the following conditions: 15.1 If the problem is service performance, contractor will be warned either verbally or in writing of unsatisfactory performance and intent to cancel this contract. Contractor will be given a period of time to „cure‟ the performance. If performance does not improve contractor will be given 30 days written notice that the contract will be cancelled. Upon termination, WisDOT‟s liability will be limited to the pro rata cost of the services performed as of the date of termination. 15.2 In the event the contractor terminates the contract, for any reason whatsoever, it will require written certified letter notification delivered to the Department purchasing agent not less than 60 days prior to said termination. The contractor will, in turn, refund the Department, within 30 days of said termination, all payments made hereunder by the Department to the contractor for work not completed. If at any time a petition in bankruptcy shall be filed against the contractor and such petition is not dismissed within 90 calendar days, or if a receiver or trustee of contractor's property is appointed and such appointment is not vacated within 90 calendar days, WisDOT has the right, in addition to any other rights of whatsoever nature that it may have at law or inequity, to terminate this Contract by giving 90 calendar days notice in writing of such termination.

15.3

16.

CERTIFICATION FOR COLLECTION OF SALES AND USE TAX
The State of Wisconsin shall not enter into a contract with a vendor, and reserves the right to cancel any existing contract, if the vendor or contractor has not met or complied with the requirements of s.77.66, Wis. Stats., and related statutes regarding certification for collection of sales and use tax.

17.

DISPOSTION OF UNUSED MATERIALS
The Certificate of Title is a secured form. The vendor must insure that samples, excess and unused materials are properly safeguarded during production and destroyed at the end of each production run. Material must not fall into wrong hands or become improperly used. This includes plates and other material used in production of the forms.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 6 of 13

18.

PRODUCTION TIME ALLOWANCES
Forms shall be delivered to WIDOT within forty-five working days upon receipt of order. These allowances include shipping, composition, proof sending and return time. Vendor pays shipping charges.

19.

PROPERTY
All source artwork, copy, film, negatives, and other supplied material by the WIDOT and that which is created by the vendor is to be regarded as the property of WIDOT and returned upon request or at the end of or termination of the contract period.

20.

NEW TECHNOLOGY
The contractor may be allowed to increase (or decrease) pricing as new technology is created within the term of the contract. If there are new security features developed for the title paper, the contractor may be asked to implement them into the current contract. Also, the contractor may be asked to incorporate changes as printers are upgraded. The contractor must show evidence of the price increase in order to be allowed price increases.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 7 of 13

STATE OF WISCONSIN
DOA-3477 (R05/98)

ATTACHMENT A

VENDOR INFORMATION
1. BIDDING COMPANY NAME FEIN (Federal Employer ID Number) Phone FAX Address City State Zip + 4 ( ( ) ) OR Social Security # (if sole proprietorship) ( )

Toll Free Phone E-Mail Address

2.

Name the person to contact for questions concerning this bid. Name Title Phone FAX Address City State Zip + 4 ( ( ) ) Toll Free Phone E-Mail Address ( )

3.

Any vendor awarded over $25,000 on this contract must submit affirmative action information to the department. Please name the Personnel / Human Resource and Development or other person responsible for affirmative action in the company to contact about this plan. Name Title Phone FAX Address City State Zip + 4 ( ( ) ) Toll Free Phone E-Mail Address ( )

4.

Mailing address to which state purchase orders are mailed and person the department may contact concerning orders and billings. Name Title Phone FAX Address City State Zip + 4 ( ( ) ) Toll Free Phone E-Mail Address ( )

WISCONSIN DEPARTMENT OF TRANSPORTATION STATE OF WISCONSIN DOA-3478 (R12/96) ATTACHMENT B

BID # 262387 Page 8 of 13

REFERENCES
VENDOR:
Provide company name, address, contact person, telephone number, and appropriate information on the product(s) and/or service(s) used for requirements similar to those included in this solicitation document. Potential subcontractors cannot be references. Any subcontractor arrangement for the completion of this work shall be listed on a separate id page.

Company Name Address (include Zip +4) Contact Person Product(s) and/or Service(s) Used Phone No.

Company Name Address (include Zip +4) Contact Person Product(s) and/or Service(s) Used Phone No.

Company Name Address (include Zip +4) Contact Person Product(s) and/or Service(s) Used Phone No

Company Name Address (include Zip + 4) Contact Person Product(s) and/or Service(s) Used Phone No.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 9 of 13

Attachment C

WisDOT MINORITY BUSINESS ENTERPRISE (MBE) PROGRAM AWARENESS, COMPLIANCE & ACTION PLAN
As a matter of sound business practice, the Wisconsin Department of Transportation is committed to “supply diversity” by promoting the use of minority business whenever and wherever possible. Further, as an agency of the State of Wisconsin, WisDOT shares in the state goal of placing five (5) percent of its total annual purchasing dollars with state-certified minority businesses. State of Wisconsin procurement policy provides that Minority Business Enterprises (MBE) certified by the Wisconsin Department of Commerce, Bureau of Minority Business Development should have the maximum opportunity to participate in the performance of its contracts/projects. You, as a contractor, are strongly urged to use due diligence to further this policy by awarding subcontracts to minority-owned business enterprises or by using such enterprises to provide goods and services incidental to this agreement (second-tier suppliers), with a goal of awarding 5% of the contract cost to such enterprises. Monthly or Quarterly reports are requested to be submitted to the Department of Transportation Purchasing Unit, itemizing the costs of services and goods provided by certified firms. Reports should state the costs for the previous contract/project month or quarter. Authority for the MBE program is found in Wisconsin Statutes 15.107(2), 16.75(4), and 16.755 and 560.036(2), and details about the program can be found at: http://www.doa.state.wi.us/pagesubtext_detail.asp?linksubcatid=36 Your complete response on the following attachment must address the following components of your company’s/organization’s commitment/action plan: a) Indication that you understand the WisDOT’s goal, b) Listing of any MBE vendors with which you intend to subcontract, c) Description of the various second tier MBE expenses (goods and services procured that are incidental to the contract/project; examples are: specific office supplies to perform the contract, percentage of cost for uniforms for contract staff, travel to perform the contract/project, percentage of facility maintenance services for your facility used directly by your staff during the contract/project period) your company/organization will be able to report that are in direct connection with the administration of this contract, d) Statement expressing your commitment to complete the required monthly or quarterly reports that will reflect your subcontracts and second-tier expenditures for the period. For information on certified State of Wisconsin Minority Business Enterprises, please contact: E. Aggo Akyea Minority Business Program Specialist Wisconsin Department of Transportation 4802 Sheboygan Avenue, Room 751 P O Box 7915 Madison, WI 53707 (608) 267-2886 (608) 267-3609 fax aggo.akyea@dot.state.wi.us A partial listing of some certified minority business enterprises qualified for this request for bid follows. A complete listing of certified minority businesses, as well as the services and commodities they provide, is available on the web at: http://www.doa.state.wi.us/deo/mbe/minority_search.asp and Information regarding certification of minority businesses is available at: http://www.commerce.state.wi.us/ED/ED-MBD-Certification.html.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 10 of 13

Potential MBE Printers - Bidders and Subcontractors
4 Star Printing 3947 N. Teutonia Avenue Milwaukee, WI 53206 Murphy Jamerson, Director of Operations 414/449-0620 414/449-0622 jamersonm4@aol.com County: Milwaukee Product/Service: Commercial printing services Abisco Products, Inc 10612 Pioneer Blvd Santa Fe Springs, CA 90670-3709 Angel Munoz, President 562/906-9330 562/906-9333 abisco@earthlink.net County: Product/Service: Manufacture of binders and index tabs. Printing and promotional products. All Printing & Paper, LLC 1480-B Martin Street P O Box 259316 Madison, WI 53725-9316 Al Franklin, President 608/217-2071 608/833-1641 biscayne@tds.net County: Dane Product/Service: All printing services and supply of paper. Printing brokerage services. Business Graphics & Printing, Inc. 1337 Pearl Street Waukesha, WI 53186-5613 Julian Moncada, President 262/521-1400 262/521-3077 busgraphics@ameritech.net County: Waukesha Product/Service: Full service commercial and color offset printing. Short and long runs for cut sheet, and continuos forms, labels, specialty products and stationary. Color copier center Product/Service: Printing, graphic and web design, database management and mailing services. Copy N' More, Inc. 7100 W. Fond Du Lac, #101 Milwaukee, WI 53218-3847 Theophilus Iyasele, President 414/536-7512 414/536-7516 copynmore@Ameritech.net www.copynmore.com County: Milwaukee Product/Service: Copy and print center specializing in blueprinting, oversize copies, high speed copies, color copying, printing, rubber stamps, paper supplies and binding services. L.O.R. & Associates, Inc. 816 West National Avenue Milwaukee, WI 53204 Luis O. Rodriguez, President 414/643-1999 414/643-9383 County: Milwaukee Product/Service: Printing, publishing, and bindery products. Hispanic yellow pages and resource guide. Business Support, LLC 1509 Rapids Drive Racine, WI 53404 Naison Nyamatutu, Managing Director 262/632-0080 262/632-6849 naison@businesssupport.net www.businesssupport.net County: Racine

NCON Communications Corporation, Inc. 1938 N Dr ML King Dr Milwaukee, WI 53212-0167 Nathan Conyers, President 414/263-5088 414/263-4445 miltimes@execpc.com County: Milwaukee Product/Service: Newspaper, advertising, typesetting, and printing. Quick offset printing, desktop publishing, advertising, signs and banners, and mailing services.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 11 of 13

Northview Printing, Inc. 10230 W. Fond du Lac Ave. Milwaukee, WI 53224-5195 John F. Duffek, President 414-353-1220 414-353-7168 northviewptg@merr.com County: Milwaukee Product/Service: Printed products for small businesses including letterhead, envelopes, business cards, brochures, sales materials, paper, medical forms, etc. Oneida Printing 2701 West Mason Street PO BOX 365 Oneida, WI 54155-0000 Bruce Steinfeldt, Print Manager 414/494-4006 414/496-7896 bsteinfe@oneidanation.org County: Brown Product/Service: Offset and full color printing, graphics designs and layout, typesetting, full bindery service, bulk mailings, letterpress, perforating, die cutting and laminating. PAP Security Printing, Inc 1813 Colonial Village Lane Lancaster, PA 17601 Mike Robinson, President 717/399-3333 717/394-3333 mrobinson_pap@paonline.com www.papsecurity.com County: Product/Service: Printing of online lottery ticket stock, betting slips and bank ATM receipts. Printing warehouse services. Printing, automation, control panel distributor and services. Perfect Image 503-D Commerce Park Drive Marietta, GA 30060-0000 Joi Jackson, Account Representative 770/442-4221 770/427-8708 jopimage@hotmail.com County: Product/Service: Commercial printing. Printing of brochures, pocket folders, posters, display tickets, newsletters, and annual reports.

Shekinah Printing & Design 2317 N Martin Luther King Blvd Milwaukee, WI 53212 Luc Monsanto, Owner 414/263-2679 414/263-4082 shekinah_printing@ameritech.net County: Milwaukee Product/Service: Commercial printing of business cards, brochures, banners, wedding invitations. Photo copying and graphic design services. Vilar Arts, Inc. 7954 Harwood Avenue Wauwatosa, WI 53213-0000 Bob Vilar, CEO 414/778-0665 414/778-2398 vilararts@vilararts.com County: Milwaukee Product/Service: Full service printing and graphic arts for brochures, forms, booklets, and flyers. Xpress Copy 2821 N 4th Street, Suite 219 Milwaukee, WI 53212 Leonard McGhee, Owner 414/385-0417 414/385-0419 mcgheecatfish@aol.com County: Milwaukee Product/Service: Full service printing of envelopes, letterheads, business cards, brochures, pamphlets and books. Z-3 Graphics 106 East Melvina Street Milwaukee, WI 53212 Fred V. Zirbel III, Owner 414/963-6101 414/963-9404 Z3Graphics@hotmail.com County: Milwaukee Product/Service: Printing, variable data, numbering, continuos forms, die-cutting and pre-press services.

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 12 of 13

ATTACHMENT C

WisDOT MINORITY BUSINESS ENTERPRISE (MBE) PROGRAM AWARENESS, COMPLIANCE & ACTION PLAN
Complete, sign, and include in your bid reponse. Failure to complete this form as a component of your bid may result in rejection of your bid. Our company/organization is a Wisconsin-certified Minority Business Enterprise (MBE). Our company/organization is a minority business but has not yet received Wisconsin certification (please provide details): _____________________________________________ We are aware of the WisDOT‟s goal to spend at least 5% of their total annual purchasing dollars with state-certified MBE firms. We are aware that if awarded this contract/project our company/organization will provide monthly or quarterly reports to WisDOT reporting all expenditure activity directed to MBE subcontractors or second-tier MBE suppliers that directly relate to this contract. (Any noncertified minority businesses could be a potential subcontractor/second-tier supplier--indicate these on your plan. WisDOT will work with those businesses for possible certification.) Subcontractors: Our company/organization intends to subcontract at least 5% dollar volume with certified MBE firms listed below (names, addresses, telephone numbers):  Yes  Yes  Yes  Yes  No  No  No  No

 Yes

 No

Second-tier Suppliers: In addition to direct subcontracting efforts, your company/organization can help WisDOT achieve the 5% goal by managing your second-tier minority purchases. Second-tier business refers to incidental business expenses your company may spend with Wisconsin-certified MBE firms as it pursues the normal course of business supplying the WisDOT-contracted products or services. Here are some examples:  Percentage of your office supplies specifically used during the course of this contract/project.  Percentage of uniform costs for staff performing this contract/project.  If you travel to perform this contract/project, you could use a state-certified MBE travel agency and report that expense.  Percentage of facilities maintenance services for facility(ies) directly used by your staff during the course of this contract/project. These second-tier expenses can only be reported to the extent that they directly relate to your business with WisDOT. The percentage of the expense you can report is determined by the amount of your WisDOT sales as it relates to your total sales volume. Per the terms of your contract, you should actively pursue directing business towards these types of companies, and report your efforts in this regard on a monthly basis. ************************************************************************************************************************************* In paragraph form, describe your company/organization‟s commitment/action plan with regard to the planned use of state-certified MBE businesses in subcontracting efforts, as well as developing MBE second-tier suppliers. Please list your specific commitments (attach sheet, if necessary).

SIGNATURE: ______________________________________ DATE: _____________________________ PRINTED NAME & TITLE: _______________________________________________________________ COMPANY: ____________________________________________________________________________

WISCONSIN DEPARTMENT OF TRANSPORTATION

BID # 262387 Page 13 of 13

MINORITY BUSINESS PARTICIPATION REPORT
Wisconsin Department of Transportation DT1230 8/2006 s.16.75(3m) Wis. Stats.

Return via FAX to: OR Return via e-mail to:
Report Date

608-267-3609, ATTN: Purchasing Minority Business Coordinator tipscorrespondence.dbm@dot.state.wi.us
Contract / Purchase Order # Time Period Covered by Report

Monthly: Quarterly:
Project Name / Contract Title Prime Vendor / Contractor Name

#1

#2

through #3

#4

Federal Employer Identification Number – FEIN

Minority Vendor Contractor Name, Address and Telephone Number

Product / Service Purchased

Subcontract $ Amount

Second Tier $ Amount

If no business was awarded to Minority Business Enterprises (MBE) for this period, please describe the efforts made to encourage minority business participation. If you have questions, please call the WisDOT Minority Business Program Specialist, 608-267-2886. _______________________________________________________________________________________________ _______________________________________________________________________________________________ I certify that the information contained on this report is true and correct. I also certify that I am an authorized representative of the above-identified Prime Vendor / Contractor.
(Prime Vendor/Contractor Authorized Representative Name) (Title)


				
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