|
transacts or applies to transact business with a public entity. The term "persons" includes those
<br />officers, directors, executives, partners, shareholders, employees, members, and agents who are
<br />active in management of any entity.
<br />11.6. Based on information and belief, the statement which I have marked below is true in relation to
<br />the entity submitting this sworn statement. (Indicate which statement applies.)
<br />Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in the management of
<br />the entity, nor any affiliate of the entity has been charged with and convicted of a public entity
<br />crime subsequent to July 1, 1989.
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in the management of
<br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity
<br />crime subsequent to July 1, 1989.
<br />The entity submitting this sworn statement, or one or more of its officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in the management of
<br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity
<br />crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a
<br />Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order
<br />entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the
<br />Final Order entered by the Hearing Officer determined that it was not in the public interest to
<br />place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of
<br />the final order.)
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY
<br />AND, THAT THIS FORM IS VALID THROUGH DECEMB R 31 OF THE CALENDAR YEAR IN WHICH IT IS
<br />FILED. I ALSO UNDERSTAND THAT I AM REQUIR TO INFORM THE PUBLIC ENTITY PRIOR TO
<br />ENTERING INTO A CONTRACT IN EXCESS OF TH THRESHOLD AMOUNT PROVIDED IN SECTION
<br />287.017, FLORIDA STATUTES, FOR CAT[GORY 0
<br />n OF ANY, CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM.
<br />By:
<br />1,41�f, III?-/fl�E_) /L
<br />(Printed Name% -
<br />-31
<br />(Title)
<br />Sworn to and subscribed before me this „/ day of r 7 , 20 by
<br />NOTARY PUBLIC -STATE OF FLORIDA
<br />(AFFIX NOTARY STAVRIE E) Kurt V. Ingram
<br />Commission #DD723885 Signatu e: Nota is — State of Florida
<br />Expires: OCT. 19, 2011
<br />BONDED THRUATI ,ANTIC BONDING 00.,INC. Print or Type Commissioned Name
<br />Personally Known y OR Produced Identification
<br />Type of Identification Produced
<br />END OF SECTION
<br />PAGE 88 OF 105
<br />PROPOSAL NO.
<br />C__
<br />
|