|
<br />II
<br />
<br />LJ
<br />
<br />II
<br />
<br />LJ
<br />
<br />181ST ACTIVE PARK
<br />
<br />APRIL 10,2005
<br />
<br />II
<br />
<br />6,
<br />
<br />Based on information and belief, the statement which I have marked below is true in relation to the
<br />entity submitting this sworn statement. [Indicate which statement applies]
<br />
<br />-X Neither the entity submitting this sworn statement, nor any of its officers, directors,
<br />exec~i'ives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a
<br />public entity crime subsequent to July I, 1989.
<br />
<br />LJ
<br />
<br />n
<br />
<br />LJ
<br />
<br />LJ
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a
<br />public entity crime subsequent to July 1, 1989,
<br />
<br />II
<br />
<br />n
<br />
<br />LJ
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in the
<br />management of the entity, nor any affiliate of the entity has been charged with and convicted of a
<br />public entity crime subsequent to July I, 1989. However, there has been a subsequent proceeding
<br />before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
<br />Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings
<br />and the Final Order entered by the Hearing Officer determined that it was not in the public interest
<br />to place the entity submitting this sworn statement on the convicted vendor list. [attach a copy of
<br />the final order]
<br />
<br />n
<br />
<br />LJ
<br />
<br />II
<br />
<br />LJ
<br />
<br />n
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
<br />u FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
<br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE
<br />II CALENDAR YEAR IN WHICH IT IS FILED, I ALSO UNDERSTAND THAT I AM REQUIRED TO
<br />INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE
<br />U THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR
<br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CON NED IN S FORM.
<br />
<br />LJ
<br />
<br />,..Y)
<br />Sworn to and subscribed before me this 7-
<br />
<br />
<br />(I
<br />
<br />LJ
<br />
<br />11
<br />
<br />day of
<br />
<br />I t/ rJ'C::-
<br />_....../
<br />
<br />20 i; r-
<br />, -
<br />
<br />n
<br />
<br />Personally known
<br />OR Produced identification.._ll j;~~I/ j, L
<br />
<br />''') ,':' -----. /'
<br />~ . //. <.,L-;,~
<br />'0<;'-&~--! ,F~__ .
<br />Notary Public - State of/!J.~//.v./f2--
<br />
<br />II
<br />
<br />LJ
<br />
<br />LJ
<br />
<br />n
<br />
<br />(Type of identification)
<br />
<br />".", "', DELI" l LEE
<br />"', ..'" ... c' uv COI.\h\\SSION i DD i5~2,2
<br />~, rl ,,~ l'ill
<br />. ",~;;i,' EXPIRES', Oclober19, 2006
<br />d, " "~'~ \,:-:: oonaeo Hille Bullqe\ NOl4l~ ServlCt5
<br />
<br />My commission expires "t';- /'-f-c.t.
<br />
<br />LJ
<br />
<br />n
<br />
<br />(Printed typed or stamped
<br />commissioned name of notary public)
<br />
<br />LJ
<br />
<br />n
<br />
<br />LJ
<br />
<br />II
<br />
<br />u
<br />
<br />II
<br />
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
<br />
<br />Li
<br />
|