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 STAFFING PLAN (Form 4)
Submit with Bid or Proposal
General instructions: All Offerors and each subcontractor identified in the bid or proposal must complete an EEO Staffing Plan (MWBE 101) and submit it as part of the bid or
proposal package. Where the work force to be utilized in the performance of the State contract can be separated out from the contractor’s and/or subcontractor’s total work
force, the Offeror shall complete this form only for the anticipated work force to be utilized on the State contract. Where the work force to be utilized in the performance of the
State contract cannot be separated out from the contractor’s and/or subcontractor’s total work force, the Offeror shall complete this form for the contractor’s and/or
subcontractor’s total work force.

Instructions for completing:

1. Enter the Solicitation number that this report applies to along with the name and address of the Offeror.
2. Check off the appropriate box to indicate if the Offeror completing the report is the contractor or a subcontractor.
3. Check off the appropriate box to indicate work force to be utilized on the contract or the Offerors’ total work force.
4. Enter the total work force by EEO job category.
5. Break down the anticipated total work force by gender and enter under the heading ‘Work force by Gender’
6. Break down the anticipated total work force by race/ethnic identification and enter under the heading ‘Work force by Race/Ethnic Identification’. Contact the OMWBE
Permissible contact(s) for the solicitation if you have any questions.
7. Enter information on disabled or veterans included in the anticipated work force under the appropriate headings.
8. Enter the name, title, phone number and email address for the person completing the form. Sign an d date the form in the designated boxes.

RACE/ETHNIC IDENTIFICATION
Race/ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. For the purposes of this form,
an employee may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be
counted in more than one race/ethnic group. The race/ethnic categories for this survey are:

• WHITE- (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
• BLACK- a person, not of Hispanic origin, who has origins in any of the black racial groups of the original peoples of Afr ica.
• HISPANIC- a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
• ASIAN & PACIFIC ISLANDER- a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.
• NATIVE INDIAN (NATIVE AMERICAN/ALASKAN NATIVE)- a person having origins in any of the original peoples of North America, and who maintains cultural
identification through tribal affiliation or community recognition.

OTHER CATEGORIES

• DISABLED INIDVIDUAL- any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies)
- has a record of such an impairment; or
- is regarded as having such an impairment.
• VIETNAM ERA VETERAN - a veteran who served at any time between and including January 1, 1963 and May 7, 1975.
• GENDER- Male, Female or X
Form #4 -Page 1 of 1
 STAFFING PLAN (Form 4)

Solicitation No.: Reporting Entity: Report includes Contractor’s/Subcontractor’s:

□ Work f orce to be utilized on this contract
□ Total work f orce
Offeror’s Name: □ Of f eror
□ Subcontractor
Offeror’s Address: Subcontractor’s name________________

Enter the total number of employees for each classification in each of the EEO-Job Categories identified
Work force by
Work force by Gender
Race/Ethnic Identification

Total
EEO-Job Category Work Total Total Total
force
Native
Male Female X White Black Hispanic Asian Disabled Veteran
American
(M) (F) (X) (M) (F) (X) (M) (F) (X) (M) (F) (X) (M) (F) (X) (M) (F) (X) (M) (F) (X) (M) (F) (X)

Officials/Administrators

Professionals

Technicians
Sales Workers
Office/Clerical

Craft Workers
Laborers
Service Workers
Temporary
/Apprentices

Totals

PREPARED BY (Signature): TELEPHONE NO.: DATE:

EMAIL ADDRESS:

NAME AND TITLE OF PREPARER (Print or Type): Submit completed with bid or proposal MWBE 101 (Rev 03/11)
 - M/WBE Form #5 –
MINORITY AND WOMEN-OWNED BUSINESS ENTERPRISES –
EQUAL EMPLOYMENT OPPORTUNITY POLICY STATEMENT

M/WBE AND EEO POLICY STATEMENT

I, _________________________, the (awardee/contractor)____________________ agree to adopt the following

policies with respect to the project being developed or services rendered at
____________________________________________________________________________

M/WBE
This organization will and will cause its
contractors and subcontractors to take good faith actions to
achieve the M/WBE contract participations goals set by the
State for that area in which the State-funded project is
located, by taking the following steps:
Actively and affirmatively solicit bids for contracts and
subcontracts from qualified State certified MBEs or WBEs,
including solicitations to M/WBE contractor associations.
Request a list of State-certified M/WBEs from AGENCY and
solicit bids from them directly.
Ensure that plans, specifications, request for proposals and
other documents used to secure bids will be made available in
sufficient time for review by prospective M/WBEs.
Where feasible, divide the work into smaller portions to
enhanced participations by M/WBEs and encourage the
formation of joint venture and other partnerships among
M/WBE contractors to enhance their participation.
Document and maintain records of bid solicitation, including
those to M/WBEs and the results thereof. Contractor will also
maintain records of actions that its subcontractors have taken
toward meeting M/WBE contract participation goals.
Ensure that progress payments to M/WBEs are made on a
timely basis so that undue financial hardship is avoided, and
that bonding and other credit requirements are waived or
appropriate alternatives developed to encourage M/WBE
participation.
_________________________________________________
Name & Title
_________________________________________________
Signature & Date
EEO
(a) This organization will not discriminate
against any employee or applicant for employment because of
race, creed, color, national origin, sex, age, disability or marital
status, will undertake or continue existing programs of
affirmative action to ensure that minority group members are
afforded equal employment opportunities without
discrimination, and shall make and document its conscientious
and active efforts to employ and utilize minority group
members and women in its work force on state contracts.
(b)This organization shall state in all solicitation or
advertisements for employees that in the performance of the
State contract all qualified applicants will be afforded equal
employment opportunities without discrimination because of
race, creed, color, national origin, sex disability or marital
status.
(c) At the request of the contracting agency, this organization
shall request each employment agency, labor union, or
authorized representative will not discriminate on the basis of
race, creed, color, national origin, sex, age, disability or marital
status and that such union or representative will affirmatively
cooperate in the implementation of this organization’s
obligations herein.
(d) Contractor shall comply with the provisions of the Human
Rights Law, all other State and Federal statutory and
constitutional non-discrimination provisions. Contractor and
subcontractors shall not discriminate against any employee or
applicant for employment because of race, creed (religion),
color, sex, national origin, sexual orientation, military status,
age, disability, predisposing genetic characteristic, marital
status or domestic violence victim status, and shall also follow
the requirements of the Human Rights Law with regard to non-
discrimination on the basis of prior criminal conviction and
prior arrest.
(e) This organization will include the provisions of sections (a)
through (d) of this agreement in every subcontract in such a
manner that the requirements of the subdivisions will be
binding upon each subcontractor as to work in connection
with the State contract.

Form #5 -Page 1 of 1