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<br />transact business with a public entity. The term "person" includes those officers, directors,
<br />executives, partners, shareholders, employees, members, and agents who are active in management
<br />of an entity.
<br />
<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 />
<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
<br />entity, nor any affiliate of the entity has been charged with and convict~d of a public entity crime
<br />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 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 />
<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, nor any 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 of the State of Florida, Division of Administrative Hearings and the Final
<br />Order entered by the Hearing Officer determined that it was not in the public interest to place the
<br />entity submitting this sworn statement on the convicted vendor list. [attach a copy of the final
<br />order]
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
<br />FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
<br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE
<br />CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO
<br />INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE
<br />THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR
<br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN TH FORM.
<br />
<br />~
<br />
<br />
<br />Sworn to and subscribed before me this
<br />
<br />~ t ~ ") \ 'b 'I? "\, ,L'X>
<br />C ) day of 1'....( JC I , I' , ' y ,2007.
<br />
<br />-1Y1.1f) 1; 1\ (!.~
<br />I ) .....
<br />I ---
<br />
<br />Not~ry Public - State of t= I u rl dO
<br />
<br />Personally known X
<br />
<br />OR Produced identification
<br />
<br />(Type of identification)
<br />
<br />My commission expires ()( D 110; 1-:9() i (j
<br />, I
<br />
<br />I )''')nr II ~ \ L 1Y'f" ('r ~
<br />(Printed typed or stamped
<br />commissioned name of notary public)
<br />
<br />"''''1 M " J"
<br />,"~~':.~.!'.,:"!, ante Imenez
<br />_a.A.".
<br />:::' Y:; Commission # 00548534
<br />~*;... ..jp Expires June 19. 2010
<br />"S;r!;t}\\" Bonded Trov FJin . Insurance Inc 800.385.7019
<br />
<br />Oct. 2007
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
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