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Local Assistance Procedures Nhnual M MIT 10 -01 Consultant Proposal DME Commitment INSTRUCTIONS- CONSULTANT PROPOSAL DBE COMMITMENT Consultant Section TheConsultant shall: 1 L ocal Agency Name— Enter the name of the local or regional agency that isfunding the contract 2 Proj ect Location - Enter theproject location as it appears on the project advallwirent, 3 Prqj act Description - Enter thaprojeet description as It appears on theproject advertisement (BrI to Rehab, Seismic Rehab, Overlay, Widening, etc.). 4. Consultant Name- Enter the consultant'sfirmname. 5. Contract DBE Goal % - Enter the cdntra t DBE goal percentage, alit was reported on the Exhibit 10 -1 Noticeto Proposers DBE Information form. See LAPM Chapter 10. 8. Desarl ptlon of Servicesto be Provided - Enter Item of work dwilption of servicesto beforovided. Indicateall work to be performed by DBEs Including work performed by tha prime consultant's own forces, if thepdme iss DBE, If 100% of the Item is not to be performed orfurnishd by the DBE, dwibethe exact portion to be performed or furnishd by the DBE SeeLAPM Chapter 9 to determl ne how to count tha partld patios of DBE firms. 7 DBE Firm Contact I nFormation - Enter thenarna and teiephonanumber of of DBE subcontracted consultants. Also, enterthe pri me ronsultant's name and telephone number, If the prl ma i s a DBE. 8 DBE Cert. Number - Enter N DBE9 Certification Ident1ficetion Number , All DBEis must be certified on the date bids are opened, (DBE subcontracted consuitents should notify the prime consultant in writing with the date of the dECatifl cation if their status shoul d change duri ng the course of the contract ) 9 D E % - Percent partl d pation of work to be performed de aevl ca provl del by a DBE I rd ude the prime consultant if the prl me is aDISE, See LA PM Chapter 9 for how to count fulIJpati@I patid pall on 10 Total %Claimed — Enterthp total DBE part! d poll ondaj mod, If the Total ° a a] mad is I ess then I tam " 6, Contract D BE Goal an adequatel y documented Good Faith Effort (GFE) is required (sea Exhibit 15-H DBE Information - Good Faith Efforts of the LAPM). 11 Prepar er' sSi gnatura— The person comp] sit ngthissedlonof the form for the consul tant 'eflrm must dOnthdrname. 12. Preparer'sName( Print)— Cicarlyenterthenameofthepesonsign! ngthissectionoftheformfortheconsultnt, 13 Preparer'aTItIa -Enter the pod ti on/ti tie of the person d gn! ng thil s se-ti on of the form forthe corisultont 14 Date - Ente - the date thissoctlonof the form Issignedby the prepare 15 (ArW God a)Td No - Entethe arm code and tdsp hone number of the person sgning this secVonof the form for the consultant, Local Agency Section, The Local Agency representativeshall: 18 Local Agency Contract Number - Enter the Local Agency Contract Number 17 Fade -al -Aid ProjedNumber - EntertheFederal - AtdProJcotNumber. 18 Conte ad Execut jon D ate - Enter date the contract was executed and Not ce to Proceed issued Sce LAPM Chapter 1 O, page 23 19 Local Agency Rep resent at! ve Name (Pr int)- CI earl y enter Ina name of the person compidingINssecilort 20 Local Agency Rep res entativeS gnatura- The person completing thlssetionof the form for the LodAgency must sign the! r name to certify that the I nformati on i n thla and the Consultant Section of this form is compl ate and accurate. 21 Date - Enter the date the Local Agency RepresentAl ve d gns theform. 22, LocalAgancy Rep reszntativeTitle- Enta- the pod ifon/ titleof the person .dgningthiasedionof the form. 23. (AreaCode)Tel No. - Enta- the area code end telephone number of the Local Agency representativesigning this section ofthe form, 251.71 nor,,.. e 1m Page2of 2 z