|
<br />o
<br />
<br />.
<br />
<br />.
<br />
<br />.
<br />
<br />transact business with a public entity. The term "persons" includes those officers, directors,
<br />executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<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 />
<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 />
<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 />
<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 />
<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 DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS
<br />FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO
<br />ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION
<br />287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM.
<br />
<br />By: W
<br />(~ur.e)
<br />.~~~
<br />~~ ~
<br />. ~\.ct:::n\
<br />(Title)
<br />
<br />Sworn to and subscribed before me this S day of ~
<br />4\~+a A-v~m ~~Ck
<br />~\\\\" , """l
<br />(AFFIX NOTARY STAMP HERlitt\'(.~~~.~~$t~
<br />~~~ "~,"\SSla'A~"'~ ~
<br />~ .' o~'" '. p,_.. "'0 ~
<br />~ ..~t:J_,,~~ 23'<'0 ~'. ~
<br />~ :~ "'. ? ~.. ~
<br />-*. (J). -
<br />::: ... : * = Print or Type Commissione
<br />~~ \ #00758399 1 ~ ~
<br />Personally Known V \~~~\iI~~~'J~tification
<br />Type of Identification produ~&s!~b!~~".~~~~
<br />~.IIIIII~f;/r,Tt.~\~\\~D OF SECTION
<br />
<br />, 20~. by
<br />
<br />
<br />PAGE 61 OF 130
<br />BlD No. 08-10-01
<br />
|