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power to enter into a binding contract and which bids or applies to bid on contracts for the provision
<br /> of goods or services let by a public entity, or which otherwise transacts or applies to transact
<br /> business with a public entity. The term "person" includes those officers, directors, executives,
<br /> partners, shareholders, employees, members, and agents who are active in management of an
<br /> entity.
<br /> 6. Based on information and belief, the statement which I have marked below is true in relation to the
<br /> entity sub thing this sworn statement (Indicate which statement applies).
<br /> either the entity submitting this sworn statement, nor any of its officers,directors, executives,
<br /> partners, shareholders, employees, members, or agents who are active in the management of the
<br /> entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime
<br /> 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 the
<br /> entity, or an affiliate of the entity has been charged with and convicted of a public entity crime
<br /> 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 the
<br /> entity, or an affiliate of the entity has been charged with and convicted of a public entity crime •
<br /> subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing
<br /> Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by
<br /> the Hearing 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 /> I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
<br /> PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE)ABOVE IS FOR THAT PUBLIC ENTITY ONLY
<br /> AND,THAT THIS FORM IS VALID THROUGH DECEMBER 31 OFT E CALENDAR YEAR IN WHICH IT
<br /> IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO I -•RM THE PUBLIC ENTITY PRIOR TO
<br /> ENTERING INTO A CONTRACT IN EXCESS OF THE THRE . OLD/AMOUNT PRO SECTION
<br /> 287.017, FLORIDA STATUTES FOR CATEGORY TWO •F.• rY CHANG THE I FORMATION
<br /> CONTAINED IN THIS FORM. i�L/
<br /> i
<br /> r (Signature)
<br /> Sworn to and subscribed before me this day of� iv✓4-it9 , 20]
<br /> ersonally known i /- —
<br /> OR Pro uced Identification ,.t..•• -u di : ate of Florio. •
<br /> My commission expires
<br /> (Print .
<br /> Com sib '=''•'pameett+ yMERHf
<br /> Notary Public.State of ftorida
<br /> n „ My Comm.ti :lres Sep 6.2018
<br /> ?.
<br /> r
<br /> '+,,y••„„c,,° Commission I ff 121339
<br /> 00300- 19/26
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