Laserfiche WebLink
<br />CONFLICT OF INTEREST CERTIFICATE <br /> <br />SECTION 00320 <br /> <br />BID # SC-051l-06 <br /> <br />Bidder must execute either Section I or Section II hereunder relative 10 Florida Starute 112.313( 12). Failure to execute either section may result in <br />rejection of this bid proposal. <br /> <br />SECTION I <br /> <br /> <br />fficial or employee of the City or it's independent agencies requiring the goods or services described in lhese specifications <br />nterest in this company. <br /> <br />I nature <br /> <br />fll ;tch e, (L~e,t (I t{. t~ <br /> <br />Name of Official (type or print) <br /> <br />)Jp(.()Or <br /> <br />Comp'any Name <br /> <br />l/.flg SUn <br /> <br />;~. ( }( <br /> <br />, <br /> <br />r-t. <br /> <br />Business Address <br /> <br />Ho\lywooJ (']. <br />City, S~te, Zip Code I <br /> <br />S"y S1[ Y\1 )<1-11 C <br />. . I <br /> <br />73o}o <br /> <br />SECTION II <br /> <br />I hereby certify that lhc following named City official(s) and/or employce(s) having material financial intcrcst(s) (in excess of 5%) in this company <br />have filed Contlict of Interest Slatemcnts with the Supervisor of Elections, 105 East Monroe Street, Jacksonville, Duval County Florida, prior 10 bis:J <br />opening. <br /> <br />Name Title of Position Date of Filing <br /> . <br /> <br />Signarurc <br /> <br />Company Name <br /> <br />Name of Official (type or print) <br /> <br />Business Address <br /> <br />City, State, Zip Code <br /> <br />PUBLIC OFFICIAL DISCLOSURE <br /> <br />Section 126.112 of the purchasing Code Requires that a public official who has a financial interest in a bid or contract make a disclosure at the time <br />that the bid orcontracl is submitted or at the time that the public official acquires a financial interest in the bid or contract. Please provide disclosure, <br />if applicable, with bid. <br /> <br />Public Official <br /> <br />Position Held <br /> <br />Position or Relationship with Bidder <br /> <br />FORM C B-1 05. revised 6/1998 <br />