MassDOT Form AD3D Page 1 of 2 Last Modified: March 23, 2018 (A)
Letter of Intent/Schedule of Participation
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Disadvantaged Business Enterprise (DBE)
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Participation
(For Federally-sponsored Projects)
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NOTE TO BIDDER: THE DBE GOAL FOR THIS PROJECT SHALL NOT BE LESS THAN % (FROM SPONSOR’S
DBE PLAN). IF THIS GOAL IS NOT MET, THE BIDDER MUST SUBMIT DOCUMENTATION OF A “GOOD FAITH EFFORT”
TO THE SPONSOR, PRIOR TO CONTRACT AWARD, AS OUTLINED BY THE SPONSOR’S DBE PLAN.
AIRPORT __________________________________________________ PROJECT NO. ___________________________________
PROJECT TITLE _____________________________________________________________________________________________
Name of General Contractor
Name of DBE Contractor
Address
City
State Zip Code Phone
1. The undersigned DBE firm intends to perform work in connection with the above referenced project as:
Check One:
An individual A partnership A corporation
A joint venture with:
Other
Attach extra sheets if necessary
2. The undersigned affirms that they are a duly authorized official representing the proposed DBE and affirms that its
certification has not expired nor been revoked.
(Attach a copy of the certification letter)
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Check all that apply:
DBE
Certification Agency Certification Number
3. If awarded the contract, the undersigned intends to enter into a subcontract to perform the work described on the
following sheet for the prices indicated.
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Use a separate form for each DBE firm to be utilized on this project.
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Must be register with the MA Supplier Diversity Office (SDO) and must be listed as a DBE with a valid certification when
work is completed.
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For projects with any federal participation.
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Certification must be completed prior to Contract Award.
