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markei vu7uc wrKmi iin arrn'0 Imp aproarr at, stw tta n prvm rr cans ll�or one perw
<br />0C+1a10bj.0{ypa*r p0Fw>n A. por5 n who kwwi Ily rim rRia a pnl �rftre wi ha per&w who
<br />has been c&mvice j Cf a public CnWy crlme Wr Fiphda dwir19 the prvaedr+�j �16 rrwft shall ba
<br />cons;der&d an aMiarc_
<br />11 -5- 1 urdf:rL3nd Iha[ a 'person' as 6(!flnLLd rp Para, _ j M(1 xq! ), FI(wk a Sta%rRn, mogns any nalwal
<br />pe=on Cw oruyr otproved u ndar the Laws cir any tato or of rha LlaOod Stoles with the ke 2l: paver Tn
<br />Caper Inlu o L-mrrd:riq C*mlracl mrd whlch Bids or appt4j& to Shd on n1rKt5 ibr 1. w prormimm of goads at
<br />r4rvkAn Ivl W a prabLr- nRl[y+. of *!hl& o&,erwrlsa bmnwtp or appdcs m trnnsac# h=rwo s win Fp p
<br />entity, The 'erTn 'persorm' irwJ dv, t w e oficm, dire li ` , c-xL%m1 =, Partners, shemk%em,
<br />ernnloy eM mam , and ar�enls. wFi3 are : v�u in manaDelnr;nt ofany r; I ty-
<br />11 A- U.;6e4 ork ir,bMiaUon aril trolio4, Ihir 3L2iemcn1 tivhioM I have marked blow If, true in rc1o1 va [p tho CnDry
<br />d.ut�rn,rrin� #tib Sv.+Orrr �i�enront �Indlewl,e �f�ch �cl�lerr+ent Bp�Mat,�
<br />-- N#L W the Mill r ZiubMthN Lhr$ -owarn r.L lcmcnln r*r any of +Cs off mm 6ructm, "Ecuthea, parbreri,
<br />5hx.-aholders. emp1Dy;!�n• marts fts. cir agpmU who are act ar Me rnarmH.:�ameni of the enft nor av;}
<br />ariii�-,t, D IL* e" has baon &argbd wig grid comi�fkd u a putn1P-- maty dime s4 nt to 1
<br />I meq.
<br />The enthy &utirni[[Irg to sworn sWWment, or cm or "wro m ih orllrers direclom. Wedlmyes_ p13rnem.
<br />5-harc holders. crnploy+i*s, mems, or Writs who ars iDcM i+n Ve m m.30emnt of Tie en�ty, or iarL
<br />arf1ate at iM -em�-ty+ had Ii i rvF bd w+ h alb cmv+cted Df a puWIr, tnt,[yr crime svl NNM4 cnt to Jury 1,
<br />1 sm-
<br />The critilyr mAnTRUng Mks swum st lemeM, or ane or ;tura of iZ office, ajr0=aM, cxecUUyc pWtne .
<br />%hAreholders, empinyre mem4ers. or ppnM who arp 4.iWvo b1 the mW.3Vi7'rCnL of 1Jhe cgbly, or an
<br />0d6eu of 0w antllV Eras boon mad with ants larrricl&d Of i pLiRllc 4!�O[gy prim ZVboo nl ro J,UN 1,
<br />1969, liowcvor, iht;rc Ilms bcen a subsequent proceeding mfore a Hezdna OiRv of >bc $talc of
<br />Florida, ❑f: nx3n ql Adff niTLlratJW Hearings ;trw IJ,r_ Final Order entemd by H%e Kear;rrg OYcer of Ihc
<br />-SW c of F lurch, Divi m or Adm Aire Hearings and Llr_ F4%al Order entered by it a ung Offer
<br />dKe mi:r,od Cwt It vrr not ia1 the public it wrest In ire the er&ty submairg Llys sw= gni on dr-
<br />cmwicLL wrxkrr Ii9L (Aharh a 000y of tl,e 1`01W atdk~t_)
<br />I UNDERSTAND T NAT THE SUBMISSION OF T) -IIS FORM TO THE CON TRACT &C OFFICER FOR TFtE
<br />PUBLIC Eta T I T Y 10EN TI F I ED V4 PARAGRAPH 11.11 ONE) ABOVE ks FGR T��T P UBUC ENTITY ONLY A.Na,
<br />TEAT 'FHIS lS FORM IS VALID THROUGH DEC EMBEJR 31 OF THE CALENDAR YEAR tN WHICH fT IS FILED. I
<br />ALSO U NDERSTAND THAT I AM R EQDEED TO [INFORM THt< PUK L'G fI+`fTTY PRIOR TO ENTER I NO INTO
<br />A CON RA1:7 rN EXCESS OF TF -1 E WRESHOLD AVOLT Tf PRCMDED 1N SECTlGN :2$7,017F FLORIDA
<br />STA1rLJT7t5_ F�01`?4TEGOKY T`NO OF ANY, OFiAN{� IN THE* 1N F❑1F.1�4TIi7Tti1 irDNTA]?,rltD 11+1 T14I5 FORM.
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<br />(AFFUC WTAJ -STAMP HCIE)
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<br />Perwnally K"wR OR P Id lira tion, 1 V.Ar E
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