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Docusign Envelope ID:7208C774-7FB3-420E-A93E-5DE887787BB7 <br /> EXHIBIT 4C <br /> MBE/WBE/Section 3 <br /> Instructions: If the Respondent/Bidder is a Minority Owned Business (MOB) or Women Owned Business (WOB) <br /> or qualifies as a Section 3 business,the Respondent completes Form F.1., and if the Respondent/Bidder intends <br /> to utilize a MOB/WOB or Section 3 business in the performance of the proposed contract, the respondent <br /> /bidder completes Form F.2 p ry <br /> �w..i� V 0X.�0jid � °N A V X."id 0V N V I11( �,M T X.0jid V V*rc,i, T 0 p' V��u X. d 0T X. d V V.*rc 0V k °N V�u��,.� V. _,N X.�0jid ` V°k N,.,P °N V X d V a"W'N <br /> I, certify that ( ) is / ( ) is not <br /> a Minority Owned,Women Owned or Section 3 Business. <br /> Business Registered Name <br /> Business Registered Address 1 <br /> State of Registration: <br /> Certificate or Registration Number: <br /> Certifying Agency: <br /> This certification is a material representation of fact upon which reliance was placed when this transaction was <br /> made or entered into. The City reserves the right to withdraw or terminate the proposed contract should the <br /> representation of fact be false. <br /> Signature and Date: <br /> Printed Name: <br /> Position: <br />