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<br />6, Bas~d 011 information and beliet: the statement \vhich I have marked belo',v is true in relation to the enti~(
<br />submitting this sworn statement (Indicate which statement applies]
<br />
<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 entity, nor
<br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
<br />1,1989.
<br />
<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 entity, nor
<br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
<br />I, 1989.
<br />
<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 entity, nor
<br />any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
<br />I, 1989, However, there has been a subsequent proceeding before a Hearing Officer of the State of
<br />Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the
<br />State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
<br />determined that it was not in the public interest to place the entity submitting this sworn statement on the
<br />convicted vendor list. [attach a copy ofthe final order]
<br />
<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 ONL Y
<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 INFOR1V1 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 CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM. - ff~. '"'0)
<br />
<br />~i) :--~/
<br />
<br />'" ~gnature]
<br />
<br />S worn to and subscribed before me this \ D
<br />
<br />--
<br />day of ,,j,~ 1\.i C
<br />
<br />,20C'j
<br />
<br />Personally known
<br />
<br />/
<br />
<br />OR Produced identification
<br />
<br />Notary Public - State of ~\..C (2.. \ G> (~
<br />
<br />(Type of identification)
<br />
<br />My commission expires:::f~...1 L..\..::. lee,:;;
<br />
<br />(Printed typed or stamped
<br />commissioned name of notary pu~lic)
<br />
<br />,. i__ _'. .: ~. ~..... ' . ~
<br />
<br />,d.":. r,:,-:,..,. \'\('.'V"r,:> ~lIl"
<br />~~.." ". <I:~ \/~ ;~!.:~,.,~~..::'.::~!".: '['~('IS:77 ~~'~~.~:
<br />
<br />.... , .:';:'l:6,}fj.C~, " '.':"~
<br />
<br />. .,,' .
<br />
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
<br />
<br />03-4465
<br />
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