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04/11/2002 23:24 9529300043 LASZLO FULOP PAGE 07,f21 <br /> � Firm Name: a Certified SBE � Non SBE <br /> Address: City, State, Zip: <br /> Phane Number. Fax Number: <br /> Services or Supplies Provided: � <br /> Doliar Amount of their Cvntract: <br /> Firm Name: 0 Certified SBE O Non SBE <br /> Address: City, State, Zip: <br /> Phone Number. Fax Number: <br /> Services or Supplies Provided: <br /> �ollar Amount of their Contract: <br /> Firm Name: � Certified SBE 0 Non SBE <br /> Address: City, State, Zip: � <br /> Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> 17ollar Amount of their Contract: <br /> Firm Name: p Ce�Eified SBE O Non SBE <br /> . <br /> Address: ' City, State, Zip: <br /> Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> Dollar Amount of their ContraCt: <br /> Firm Name: � Certified SBE Cl Non SBE <br /> Address: City, State, Zip: <br /> Phone Number. �ax Number: <br /> Services or Supplies Provided: <br /> Dollar Amount of their Contract: <br /> Total Dollar Amount of Work Subcontracted to SBE Subcantractors/Suppliers $ <br /> Total Dollar Amount of Work Subcontracted to Non-SBE SubcantractorslSuppliers $ <br /> Totai Dollar Amount of Work Self-Pe�Formed . $ <br /> Total Bid/Contract " $ — <br /> Signature(s): Date: <br /> Print Name_ Title: � <br /> (Prssident/Authorized Representative) <br /> lf you have questions or�eecf assistance, ple�se„call.Joyce,Brown at(612),348-5960 or Kathy Capra at(612)348-7077. <br /> This report must be completed�signed by an authorized repres�ntative of the company, and submittec!to: <br /> Hennepin County Purchasing&Tat'geted Contract Services Division, A•2205 Government Center,3�0 <br /> South Sixth Street, Minneapolls.MN 55487-0225,Attention: Small Business Enterprise �rogram. <br /> S6E6 L. Rev. 3/4/02 <br />