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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 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.
<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 INFORM A TION CONTAINED IN THIS FORM.
<br />
<br />
<br />ry_ t~
<br />[ signature]
<br />
<br />Sworn to and subscribed before me this 'L. Y day of No" .>....- 6....r
<br />
<br />,2007,
<br />
<br />Personally known
<br />
<br />/
<br />
<br />OR Produced identification
<br />
<br />Notary Public - State of--:r;{U tit/'
<br />
<br />(Type of identification)
<br />
<br />My cormni 'n expires
<br />-2
<br />
<br />oC; -/1- () l'
<br />
<br />/
<br />I,
<br />
<br />
<br />,....., .v. Notary Public Slale of Florida
<br />! ~I '-r; Blanca Ins Madera
<br />." c.~,; My Cornrrllssion 00419124
<br />
<br />__2~~::~:~. ~;f:r.es ~~~~D~
<br />
<br />Oct. 2007
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
<br />
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