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ACTIA 2002 -26 <br /> APPENDIX D <br /> PROFESSIONAL SERVICES QUESTIONNAIRE <br /> Date <br /> Phonc <br /> Firm Name <br /> Street Address City State Zip <br /> TYPE OF ORGANIZATION (PRIME CONSULTANT SUBCONSULTANT <br /> Individual Name of Owner <br /> Corporation State of Incorporation <br /> Partnership Indicate General or Limited <br /> Name of Partners <br /> Joint Venture Joint Venture Participants <br /> BUSINESS LICENSE II <br /> OWNERSHIP INTERESTS <br /> American <br /> Asian or Indian or <br /> Pacific Alaskan <br /> Black l- Iispanic Islander Native White Women <br /> Number <br /> % Assets <br /> Owned <br /> JOINT VENTURE OWNERSHIP INTERESTS <br /> Minority Non - Minority Women <br /> Number <br /> Percentage <br /> I certify that I am not an employee attic Alameda County Transportation Authority and that no member /partner of this <br /> firm is employed by the Alameda County Transportation Authority <br /> Signature <br /> Firm <br /> Address <br /> Alameda County Transportation Authority Page E -22 <br /> Local Business Enterprise and Small Local Business Enterprise Program <br />