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� <br /> ' <br /> Hennepin County <br /> � Small Business Enterprise Program <br /> Prime Contractor's/Supplier's Participation Form <br /> � Project Name: Project Number: <br /> Prime Contractor's/Supplier's Name: <br /> Phone Number: Fax Number: <br /> Contract SBE Goal: °/a Total SBE Participation: % <br /> � Total Dollar Amount(Initial NTE)of Contract: <br /> Total Dollar Amount of Work Self-PerFormed: <br /> I (If entire dollar amount of contracf, as indicated on Prime's/Supplier's SBE Participation Form, wi!!be se/f- <br /> performed by the confractor in question,you may stop here after signing and dating fhe form.) <br /> � Joint Venture Partner(if any): G Certified SBE O Non SBE <br /> Address: <br /> Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> � Doltar Amount of their Contract: %of Joint Venture's Based Bid: <br /> ' List all 1 g`tier subcontractors/suppliers and the dollar walue of their contracts: <br /> Firm Name: O Certified SBE 0 Non SBE <br /> � Address: <br /> Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> Dollar Amount of their Contract: <br /> � Firm Name: O Certified SBE 0 Non SBE <br /> Address: <br /> Phone Number. Fax Number: <br /> � Services or Supplies Provided: <br /> Dollar Amount of their Contract: <br /> � Firm Name: G Certified SBE � Non SBE <br /> Address: <br /> Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> � Dollar Amount of their Contract: <br /> Firm Name: O Certified SBE G Non SBE <br /> � Address: <br /> Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> � Dollar Amount of their Contract: <br /> Firm Name: G Ce�tified SBE O Non SBE <br /> Address: <br /> I Phone Number: Fax Number: <br /> Services or Supplies Provided: <br /> Dollar Amount of their Contract: <br /> � <br /> � Hennepin County P�ime ContraGors Form HC/TCS SBE6 9IOQ R <br />