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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 /> Vt..-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 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 CHAN E IN THE INFORMATION <br /> CONTAINED IN THIS FORM. <br /> / (Signature) <br /> Sworn <br /> Sworn to and subscribed before me this �_ day o•i , 20/4. <br /> �idP <br /> Personally known jr ' / <br /> OR Produced Identification Notary Public, State of Florida-At-Large <br /> My commission expires 0-0/2-o/l <br /> (Printe• •,•!.• - -•••-• <br /> Comm..sipawc(;t)ame ofuSOtsary+pODFk) <br /> ;:', .'Fs Notary Public -State of Florida <br /> : + : •_ My Comm.Expires Aug 29.2018 <br /> t Commission x FF 118289 <br /> -N •�.L - Bonded Uri*Nalicnal Notary Assn. <br /> t. <br /> 00300-19126 <br />