Specifications

WISCONSIN DEPARTMENT OF BID #268246 TRAFFIC DATA RECORDERS
TRANSPORTATION PAGE 21 OF 23
ATTACHMENT D
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:
608-267-3609, ATTN: Purchasing Minority Business Coordinator
[e-mail]
Report Date
Contract / Purchase Order #
Time Period Covered by Report
Monthly:
through
Quarterly: #1
#2
#3
#4
Project Name / Contract Title
Prime Vendor / Contractor Name
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)