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<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.
<br />
<br />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 />e
<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 T NFORMATION
<br />CONTAINED IN THIS FORM.
<br />
<br />(Sig~ture)
<br />V> 13GtJ
<br />(prinled Name)
<br />EN fJJ/tL.
<br />(Title)
<br />
<br />
<br />ez
<br />MItN A-~GJ2.
<br />
<br />By: X
<br />
<br />Sworn to and subscribed before me this }f
<br />
<br />(AFFIX NOTA
<br />
<br />"""" JA V iWELLING
<br />. 'S~AMPM-fERE)assION # 00689758
<br />":t..WII4 EXPIRES; JUlIe 27. 2011
<br />.....rP" Fl NOI8Iy DisccuDt Assoc. Co.
<br />I~AIlY .
<br />
<br />
<br />, 202L., by
<br />
<br />c
<br />
<br />Print
<br />
<br />Personally Known ~ OR Produced Identification
<br />Type of Identification Produced
<br />
<br />END OF SECTION
<br />
<br />PAGE 61 OF 130
<br />BID No. 08-10-01
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