Form1(rev.04/2016)  DBEContractor/SubcontractorProjectTruckerandEquipmentList
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ContractIdentificationNumber____________________________
ProjectNumber(s)_______________________________________
Route(s)_______________________________________________
DollarValueofDBEWork@Bid$___________________________(seenoteonPage3)
DBECreditAmount(60%)$________________________________
Estimated_____________forCommitment(seenoteonPage3)
Completetheformbelowtoverifytheemployees(drivers)andthespecifictrucks/tankersthatwillbeusedbytheDBESubcontractortoperforma
CommercialUsefulFunctionforthespecificproject.ThisformwillneedtobesubmittedtoMoDOTpriortothebeginningofLiquidAsphalt
Operations.
Employees:
LastName FirstName AllDriverNumbers,IfMultiple
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Submit Form
Gallons
Form1(rev.04/2016)  DBEContractor/SubcontractorProjectTruckerandEquipmentList
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Trucks:
Truck
Year
Truck
Make
Truck
Model
TruckVIN#orID Leaseor
Own
Truck
IfOwned,
WhoOwnsthe
Truck?
IfLeased,
WhoDoYouLeasetheTruck
From?
1
2
3
4
5
6
7
8
9
10
11
12
Tankers:
Tanker
Year
Tanker
Make
Tanker
Model
TankerVIN#orID Leaseor
Own
Tanker
IfOwned,
WhoOwnsthe
Tanker?
IfLeased,
WhoDoYouLeasetheTanker
From?
1
2
3
4
5
6
7
8
9
10
11
12
Example: 2015
Example: 2015
Form1(rev.04/2016)  DBEContractor/SubcontractorProjectTruckerandEquipmentList
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NOTE:Toreceivefullcredit,30%ofthisamountmustbehauledwithDBE’sowntruck,tanker,trailer,andemployee.70%maximumofthe
commitmentamountmustbehauledunderLongTermLeaseagreements,whichmustallbesubmittedtoECR.
DBESignature:
______________________________________ Date:___________________
REQUIRED: Check mark to indicate that you are authorized to sign and date this form.
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