E. Agreement Amount D. Items of Work, Services or Supplies to be Provided C. Estimated Start/End Date B. Certifications/ Designations F. 60% Supplier or Broker Credit Agreement Amount A. List all Firms (Subcontractors and Suppliers) Name, address, phone number and email address for each Firm. (Check appropriate box if Firm is a certified MWBE or SDVOB.) TA-W3239 (07/2019) UTILIZATION PLAN (CONTRACTOR) Email completed form to the Bureau of Purchasing at MWBEProcurement@thruway.ny.gov or mail to 200 Southern Blvd., Albany, NY 12209 Contractor Name and Address $ Preparer's Name (Print) Date Submitted INSTRUCTIONS: This form must be submitted by the contractor to identify all certified MWBEs and SDVOBs. Complete and accurate forms must be submitted within 10 business days of the notice of tentative contract award to [email protected]Prepared by: Page 1 of 4 Supplier @ 60% $ COMPLIANCE UNIT USE ONLY: Modified Plan (Check if modified) Approved Modification Approved Conditionally Approved SDVOB WBE MBE $ $ SDVOB WBE MBE Supplier @ 60% $ $ $ SDVOB WBE MBE Supplier @ 60% $ $ $ SDVOB WBE MBE Supplier @ 60% $ $ Phone No. - ) ( Chief Compliance Officer Signature Date Broker (Fee Only) Broker (Fee Only) Broker (Fee Only) Broker (Fee Only) Preparer's Signature Email Address IFB/RFP/Contract No. Proposal No. % - $ % - $ MBE Sub Total $ WBE Sub Total $ Grand Total $ Submission: Submission: Submission: Submission: Subcontractor/Supplier To: Subcontractor/Supplier To: Subcontractor/Supplier To: Subcontractor/Supplier To: % % % Start Date End Date Start Date End Date Start Date End Date Start Date End Date Contract Value Contract Goals MBE WBE SDVOB % - $ $ SDVOB Sub Total $
Transcript
E. AgreementAmount
D. Items of Work, Servicesor Supplies to be Provided
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
A. List all Firms (Subcontractors and Suppliers)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified MWBE or SDVOB.)
TA-W3239 (07/2019) UTILIZATION PLAN (CONTRACTOR)
Email completed form to the Bureau of Purchasing at [email protected] or mail to 200 Southern Blvd., Albany, NY 12209
Contractor Name and Address
$
Preparer's Name (Print)
Date Submitted
INSTRUCTIONS: This form must be submitted by the contractor to identify all certified MWBEs and SDVOBs. Complete and accurate forms must be submitted within 10 business days of the notice of tentative contract award to [email protected]
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
UTILIZATION PLAN (CONTRACTOR)
COMPLIANCE UNIT USE ONLY: Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
Page 2 of 4
$
Supplier @ 60%
$
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
A. List all Firms (Subcontractors and Suppliers) Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified MWBE and SDVOB.)
TA-W3239 (07/2019)
IFB/RFP/Contract No.
UTILIZATION PLAN (CONTRACTOR)
Page 3 of 4
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
COMPLIANCE UNIT USE ONLY: Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
$
Supplier @ 60%
$
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
A. List all Firms (Subcontractors and Suppliers)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified MWBE or SDVOB.)
TA-W3239 (07/2019)
IFB/RFP/Contract No.
Page 4 of 4
D. Items of Work, Servicesor Supplies to be Provided
E. AgreementAmount
C. EstimatedStart/End Date
B. Certifications/Designations
F. 60% Supplier orBroker Credit
Agreement Amount
COMPLIANCE UNIT USE ONLY: Approved
Modification ApprovedConditionally ApprovedChief Compliance Officer Signature Date
$
Supplier @ 60%
$
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
SDVOB
WBE
MBE
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
$
Supplier @ 60%
$
$
Broker (Fee Only)
Submission:Subcontractor/Supplier To:
Start Date
End Date
UTILIZATION PLAN (CONTRACTOR)
A. List all Firms (Subcontractors and Suppliers)Name, address, phone number and email address for each Firm.(Check appropriate box if Firm is a certified MWBE or SDVOB.)
