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<br />I
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<br />I
<br />I
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<br />includes those officers, directors, executives, partners, shareholders, employees, members,
<br />and agents who are active in management of an entity.
<br />
<br />6. Based on information and belief, the statement which I have marked below is true in
<br />relation to the entity submitting this sworn statement. [Indicate which statement applies]
<br />
<br />Neither the entity submitting this sworn statement, nor any of its officers,
<br />directors, executives, partners, shareholders, employees, members, or agents who are
<br />active in the management of the entity, nor any affiliate of the entity has been charged
<br />with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers,
<br />directors, executives, partners, shareholders, employees, members, or agents who are
<br />active in the management of the entity, nor any affiliate of the entity has been charged
<br />with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<br />The entity submitting this sworn statement, or one or more of its officers,
<br />directors, executives, partners, shareholders, employees, members, or agents who are
<br />active in the management of the entity, nor any affiliate of the entity has been charged
<br />with and convicted of a public entity crime subsequent to July 1, 1989. However, there
<br />has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division
<br />of Administrative Hearings and the Final Order entered by the Hearing Officer of the State
<br />of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing
<br />Officer determined that it was not in the public interest to place the entity submitting this
<br />sworn statement on the convicted vendor list. [attach a copy of the final order]
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
<br />THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
<br />ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
<br />WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC
<br />ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE HRESHOLD AMOUNT
<br />PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY 0 OF ANY CHANGE
<br />IN THE INFORMATION CONTAINED IN THIS FORM.
<br />
<br />
<br />[signature]
<br />
<br />A-pr,- t--
<br />
<br />, 20t;ij
<br />
<br />OR Produced identification
<br />
<br />Notary Public - State oftLn,; rl ('
<br />
<br />(Type of identification)
<br />
<br />My commission expires 0'1- d)1o'" dlJl/
<br />
<br />~ &r-i I ~ I\J ~(2-^.J fh.)~6Z
<br />(Printed typ d or stamped
<br />commissioned name of notary public)
<br />
<br />"t!l-Y PIJ~
<br />!..~ ~
<br />'~:"
<br />';; o,,~..,
<br />
<br />Notary Public State of Florida
<br />Marilyn Femandez
<br />My Commission 00645884
<br />Expires 04/26/2011
<br />
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />March 2007
<br />
<br />00402-2
<br />
<br />03-4122.D
<br />
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