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ACTIA 2002-26.01 <br />Firm Name <br />Street Address <br />TYPE OF ORGANIZATION <br />Individual <br />Corporation <br />Partnership <br />APPENDIX D <br />PROFESSIONAL SERVICES QUESTIONNAIRE <br />City State <br />(PRR,4E CONSULTANT <br />Name of Owner <br />State of Incorporation <br />Indicate General or Limited <br />Name of Partners <br />Joint Venture Joint Venture Participants <br />BUSINESS LICENSE II <br />OWNERSHIP INTERESTS <br />Zip <br />Date <br />Phone <br />SUBCONSULTANT <br />American <br />Asian or Indian or <br />Pacific Alaskan <br />Black Hispanic 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 of the 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 />