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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.
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<br />6.
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<br />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]
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<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 convicted of a public entity crime
<br />subsequent to July 1,1989.
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<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 I, 1989.
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<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]
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<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, F ORillA STATUTES FOR
<br />CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CON Al E IN THIS FORM.
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<br />Sworn to and subscribed before me this 2.B1h
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<br />OR Produced identification
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<br />day of NOvf'mbt"'V" , 2007.
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<br />Notary Public - State of t= IOlv.1c..(.
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<br />My commission expires tOJz2!20IU
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<br />(Printed typed or stamped
<br />commissioned name of notary public)
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<br />(Type of identification)
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<br />".?,^,HUO('i" (''y'NTHEA L. W AU/'. 2
<br />~ 'W. \,lY CO\I".1iSSiO\;" Dl))lJ'>711
<br />l.~\WQ< EXPIR[S u""bcr 22. 2010
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<br />"OF.f-\.-O' Fl '.;vl.u) ])'~C<)Uill A.<~,I(". Cl)
<br />[-XIHl- \-;-H ITARY
<br />
<br />Oct. 2007
<br />Form PUR 7068 (Re,'. 06/11/92)
<br />
<br />00402-2
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