Laserfiche WebLink
<br />'--"1"1I'.LI"_ .. "'I' ....1"1 ALALi:) ~ '--E...R. ~...r~,--^ ~L <br />SECTION 00320 <br /> <br />BID# SC~463~O <br /> <br />Bidder Dl.US1..execute either Section lor Section IT hereunder relative to Florida Statute 112.313(12). Failure to execute <br />either section may result in rejection of this bid proposal. <br /> <br />SECTION I <br />I hereby ceniiY that no offic ial or emp loyee of the City or it's independent agencies requ iring the goods or services <br /> <br />dDid;;;7tlc;;;:::erial fman,~1 ;nl=15;''';~rt~ ~ <br /> <br />?ature Company Name <br /> <br />jJCi"Q L. Lel1NC 14/~2t"OftSrt'"t'+- . <br /> <br />Name of Official (type or print) Business Address <br /> <br />tl-~t1, ~L-~ 33a.J(1~St6 <br />~Code . <br /> <br />SECTION II <br />I hereby certifY that the foUowing namecl City official(s) and/or employee(s) having material Iananeia! interest{s) (in <br />excess of 5%) in this company have filed Conflict of Interest Statements with the Supervisor of Elections, 105 East <br />Monroe Street, Jacksonville, Duval County Florida, prior to bid opening. <br /> <br />Name Title of Position Date of Filing <br />tvJt <br />. . <br /> <br />Signature <br /> <br />Company Name <br /> <br />Name of Official (type or print) <br /> <br />Business Address <br /> <br />City, State, Zip Code <br /> <br />PUBLIC OFFICIAL DISCLOSURE <br />Section 126.112 ofthe purchasing Code Requires that a public official who has a fmancial interest in a bid or contract <br />make ad isclosure at the time that the bid or contract is submittecl or at the time that the public official acquires a <br />fmancial interest in the bid or contract. Please provide disclosure, if applicable, with bid. <br /> <br />. Public Official <br /> <br />Position Held <br /> <br />Position or Relationship with Bidder <br /> <br />SIB <br /> <br />FORM GB-IQS" ..... 6f1'" <br />