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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 submitting this sworn statement (Indicate which statement applies).
<br /> Neither 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 OF THE CALENDAR YEAR IN WHICH IT
<br /> IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE P :LIC ENTITY P R TO
<br /> ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD ADM- P'ea IDEECTION
<br /> 287.017, FLORIDA STATUTES FOR CATEGORY TIN, OF ANY C , ' GE r HEAN����fffRMATION
<br /> CONTAINED IN THIS FORM. ///%
<br /> ( fgna .re)
<br /> Sworn to and subscribed before me this /��l� ay of as —. , 201a
<br /> rsonally knnler».
<br /> U ,I
<br /> Pe '
<br /> OR Produced Identification Notary F u, lic, S 4 of Florida-At-Large
<br /> My commission expires
<br /> (Printed typed or stamped
<br /> Commissioned name of notary public)
<br /> .�..tt.�• JACQUELINE hLVAREZ
<br /> It
<br /> MY CO'REs:0Nr9. 891521
<br /> EXPIRES:Jp 9.2019
<br /> 3+�R:. gpEitnypmlclR
<br /> 00300- 19/26
<br />
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