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<br />""nsad business with a pub];e entity. The tonn "p.,-son" ;neludes those offiws, dletors,
<br />executi ves, partners, shareholders, employees, members, and agents who are active in mariaFement
<br />~m~~ 'I
<br />
<br />6. Based on information and belief, the statement which I have marked below is true in relati~1il to the
<br />entity submitting this sworn statement. [Indicate which statement applies] .1
<br />
<br />Neither the entity submitting this sworn statement, nor any of its officers, directors, exeGutives,
<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 />subsequentto-July+,-1989; ...... ..-.. ; i
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors, exe~:utives,
<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 entit:'{ crime
<br />subsequent to July I, 1989. : I
<br />
<br />The entity submitting this sworn statement, or one or more of its officers, directors, exeGutives,
<br />partners, shareholders, employees, members, or agents who are active in the managemeh~ of the
<br />entity, nor any affiliate of the entity has been charged with and convicted of a public ent!t:r' crime
<br />subsequent to July 1, 1989. However, there has been a subsequent proceeding before a' Uearing
<br />Officer of the State of Florida, Division of Administrative Hearings and the Final Order ent6-ed by
<br />the Hearing Officer of the State of Florida, Division of Administrative Hearings and thb Final
<br />Order entered by the Hearing Officer determined that it was not in the public interest to plbce the
<br />entity submitting this sworn statement on the convicted vendor list. [attach a copy oLn\e final
<br />order] : I
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING dlf'ICER
<br />FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PYELIC
<br />ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OJ;: 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 STATUTESI FOR
<br />CATEGORY TWO OF ANY CHANGE IN THE INFORM A TION CONTAINED IN THIS FORM.
<br />
<br />[signature]
<br />
<br />
<br />Sworn to and subscribed before me this 28
<br />
<br />day of
<br />
<br />November I
<br />
<br />,2007.
<br />
<br />(Type of identification)
<br />
<br />.4"'"
<br />l~"j~ ANAI.uOPEZ
<br />N :.\ MY COMMISSION # DO 310935
<br />'Z:..... EXPIRES: April 19,2008
<br />~ W Illlh~'1l 'thnI Notary PUbIIO UndOrwtlten;
<br />
<br />,/lr-- ~ I
<br />W~ : I
<br />
<br />Notary Public _ State of F lor ~da
<br />
<br />
<br />My commission expires 1
<br />
<br />h{~ M, Lope-z; I
<br />
<br />(Printed typed or stamped : I
<br />commissioned name of notary pu lic)
<br />
<br />Personally known
<br />
<br />xxxxx
<br />
<br />OR Produced identification
<br />
<br />Oct. 2007
<br />Form PUR 7068 (Rev. 06/11/92)
<br />
<br />00402-2
<br />
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