Laserfiche WebLink
<br />I <br /> <br />executives, partners, shareholders, employees, members, and agents who are active in <br />management of any entity. <br /> <br />11.6. Based on information and belief, the statement which I have marked below is true in relation to <br />the entity submitting this sworn statement. (Indicate which statement applies.) <br /> <br />X Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of <br />the entity, nor any affiliate of the entity has been charged with and convicted of a public entity <br />crime subsequent to July 1, 1989. <br /> <br />The entity submitting this swom statement, or one or more of its officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of <br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity <br />crime subsequent to July 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 <br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity <br />crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a <br />Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order <br />entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the <br />Final Order entered by the Hearing Officer determined that it was not in the public interest to <br />place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of <br />the final order.) <br /> <br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE <br />PUBUC ENlllY IDENTIFIED IN PARAGRAPH 11.1 (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 IS <br />FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBUC 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. <br /> <br />BY:~~~ <br />~nature) S /J cL <br />Ot.A.~ . 1\.: ;( u<- <br />(pr~ed. ~ <br />(Title) <br /> <br /> <br /> <br />n subscribed before me this II <br />~ t:JA:~ <br /> <br /> <br />i~~QII\. NQtllll'Y P.Ubl~ :ltatll of Florida <br />. . l;llIif11l Mosc"'~ttJ <br />~ c.. t., A My CommiJaklft 00747355 <br />~o"t'P'" E~"Irt'lf 03/01/201< <br /> <br />ced Identification <br /> <br />END OF SECTION <br /> <br />PAGE 59 OF 78 <br />