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<br />- :.i.~Iii----"'~;.L",. .&;v~...r <br /> <br />IilzJUJ.J. <br /> <br />Certification and Signature page <br /> <br />, ' <br />I, cenify lhaa this agnaement is made witnauE prier uncSer5tanCllng. ~ c=nneczian wilt! anJ CctparaUan. rll1'll. ar per5Cn submit- <br />ling a ~oposal for !he same ma"lIIiial5.' supplies CIl' equipne.... atId is In a'~ res~ fa.. 8Ild witho~ caU&llicn-OC' ftaud.1 agree <br />cO abide by all cond~ oIlIlis ~ amt cenifY Ihall am 8I.IlI1Qri~ 10'sIgn fIlis prDfJ0581 rcr 1M pnIpOS8I' atIC ural rN . <br />proposer is in c:ampl~CCt wi1h aU ~. indudlng. but aiel Ilmilea .~ cetTlficallan requifemtmS. In ~ a pro- <br />posal, ft proposer affets and agri]es lfIar ir !,he p."posal is ~~. d'le propcset wi. ccmvey..sell. ISSi9f' ar n~ fa. ttIe <br />Scare of Flatida ~I righlS. lIde at'!c1. irI~erest in ana II.) a'~cau:ses or adjon iI may new at bereaf1eracquira'undet me ~.lNSI <br />~Uni",d SI.l. 'and"Ihe'Staca ofF'criCtafcr-pricefixing-~~!t.the-patt~commCdiliesOt-~putCh~ ---.-------- <br />. ar KCluirea by ltIe Scale 'of FICtfda, Ai the Swe's'discretion. sUCh assignment snail be niiae atIG became .treaive jJ( me time' <br />~"e purchasing agency tel'1Clers flna' paymem 10 IJ'Ie proposer. <br /> <br />(please T~ Of' Print) <br />Name af CGmf)any: <br />Address: <br />Phone: <br /> <br />'~ ~/Z~~ ~~e. . ~ ~ FL 32.'!SlJ <br />WI}-8'31,,-~'S 13 . ' . . <br />ttn-l?3t 53~t. <br />F51- '2 'ltfSlJ *1,. dt'J.1 <br /> <br />Fax 1'10.: <br />Spurs no,: <br /> <br />I have read cmcI Clmtpleted this document and attest thClt aU of.... infanaotioa <br />is to the best of my Icnowfeclse true and accvrate. <br /> <br /> <br />~=:::::~~~;:. <br />Tille: ?re.~: d-$'1- <br />Dace: l''Z-/''Z-Zf-uJt)t!J <br /> <br /> <br />,. .-,t~~>;"-r(:;~,., ~~~:, '~':v~~:ii;;l;t~~Li']:: ^,~ '~'.(:~ '~: ....~~(~~j~~~~~"t ~,~~ ~>';~~~ <br />o./"~.......----t-.Tt1L. 1':::~~xt>'o;.<~'~l~~i,~~...<,,..""'V ,"., 'V"''''' '~1' ..~-....~.~~~...<...~ '{ii:~ <br /> <br />AUIt\crized Signature <br /> <br />0818 <br /> <br />- <br /> <br />" <br /> <br />'. <br />.' <br /> <br />" <br /> <br />: ' <br /> <br />. . <br /> <br />.' <br /> <br />. ,t, <br /> <br />, . <br /> <br />PUR 71 Q6 (Ravised 11/99) <br /> <br />9of9 <br />