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DProvide the following information for every firm (DBE and non- <br />• assisted project, whether <br />Firm m Name: DBE) <br />attempt Iobtain a contract.- <br />Phone: () - - <br />Firm Address: FAX: ( ) - - <br /> Type of work/services/materials provided: <br />Number of years in business: <br />Contact Person: Title: <br />Is the firm currently certified as a DBE under 49 CFR Part <br />26? Yes .No . Check the box below for your firm's annual gross <br />receipts last year: <br />DBE Certification Eligibility (place an "X"): African <br />American -Asian Pacific American -Native American Less than $1 million <br />-Woman -Hispanic American -Subcontinent Asian <br />American Other Less than $5 million <br /> Less than $10 million <br /> Less than $15 million <br /> More than $15 million <br /> <br />Firm Name: <br />Phone: <br />()- <br />" <br />Firm Address: FAX: ( ) - - <br />Number of years in business: Type of work/services/materials provided: <br />Contact Person: Title: <br />Is the firm currently certified as a DBE under 49 CFR Part <br />26? Yes .No . Check the box below for your firm's annual gross <br />receipts last year: <br />DBE Certification Eligibility (place an "X"): African <br />American -Asian Pacific American -Native American <br />W <br />Hi <br />i <br />A <br />i Less than $1 million <br />- <br />oman - <br />span <br />c <br />mer <br />can -Subcontinent Asian <br />American Other Less than $5 million <br /> Less than $10 million <br /> Less than $15 million <br /> More than $15 million <br />Page 47 of 48 <br />19H-51