Fill - Free fillable Form1(rev.04/2016) DBE Contractor/Subcontractor Project Trucker and Equipment List (Missouri DoT) PDF form

Form1(rev.04/2016)   DBEContractor/SubcontractorProjectTruckerandEquipmentList

Page1of3

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ContractIdentificationNumber____________________________

ProjectNumber(s)_______________________________________

Route(s)_______________________________________________

DollarValueofDBEWork@Bid$___________________________(seenoteonPage3)

DBECreditAmount(60%)$________________________________

Estimated_____________forCommitment(seenoteonPage3)

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Completetheformbelowtoverifytheemployees(drivers)andthespecifictrucks/tankersthatwillbeusedbytheDBESubcontractortoperforma

CommercialUsefulFunctionforthespecificproject.ThisformwillneedtobesubmittedtoMoDOTpriortothebeginningofLiquidAsphalt

Operations.



Employees:

 LastName FirstName AllDriverNumbers,IfMultiple

1  

2  

3  

4  

5  

6  

7  

8  

9  

10  

11  

12  

13  

14  

15  

16  

17  

18  

19  

20  





Submit Form

Gallons

Form1(rev.04/2016)   DBEContractor/SubcontractorProjectTruckerandEquipmentList

Page2of3

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Trucks:



Truck

Year



Truck

Make

Truck

Model

TruckVIN#orID Leaseor

Own

Truck

IfOwned,

WhoOwnsthe

Truck?

IfLeased,

WhoDoYouLeasetheTruck

From?

1      

2      

3      

4      

5      

6      

7      

8      

9      

10      

11      

12      

Tankers:



Tanker

Year



Tanker

Make

Tanker

Model

TankerVIN#orID Leaseor

Own

Tanker

IfOwned,

WhoOwnsthe

Tanker?

IfLeased,

WhoDoYouLeasetheTanker

From?

1      

2      

3      

4      

5      

6      

7      

8      

9      

10      

11      

12      



Example: 2015

Form1(rev.04/2016)   DBEContractor/SubcontractorProjectTruckerandEquipmentList

Page3of3

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NOTE:Toreceivefullcredit,30%ofthisamountmustbehauledwithDBE’sowntruck,tanker,trailer,andemployee.70%maximumofthe

commitmentamountmustbehauledunderLongTermLeaseagreements,whichmustallbesubmittedtoECR.



DBESignature:

______________________________________ Date:___________________

REQUIRED: Check mark to indicate that you are authorized to sign and date this form.

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Form1(rev.042016) DBE ContractorSubcontractor Project Trucker and Equipment List (Missouri DoT)

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