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<br />~
<br />~
<br />
<br />~
<br />
<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 />s
<br />
<br />II
<br />
<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]
<br />
<br />~
<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 />IIlI
<br />....
<br />
<br />hi
<br />
<br />III
<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 />11II
<br />
<br />-
<br />III
<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]
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<br />111
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<br />In
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<br />
<br />-
<br />III
<br />
<br />III
<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 THIS FORM.
<br />
<br />fl\ - --
<br />
<br />[signature]
<br />
<br />III
<br />
<br />III
<br />
<br />III
<br />
<br />II
<br />
<br />Sworn to and subscribed before me this
<br />
<br />y~ \/
<br />~ day of I '-t oV
<br />
<br />,2007.
<br />
<br />II
<br />
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<br />
<br />PersonalJy known ~.~ ~f("\\
<br />
<br />\0 lY\e
<br />-
<br />
<br />d
<br />
<br />OR Produced identification
<br />
<br />Notary Public - State of
<br />
<br />II
<br />
<br />JJ
<br />
<br />(Type of identification)
<br />
<br />
<br />(PrInted typed or stampe
<br />commissioned name of notary public)
<br />
<br />II
<br />
<br />II
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<br />r,0TMlY Wm.lC -S'l't,TV r'F FID.~?nA
<br />..~t';i/j.,.; }1;int,h 1:~1 (h pI.
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<br />1l~';IDFi TRR~ ATLA~Tl\: IlONDING co.j lN~
<br />
<br />II
<br />
<br />.
<br />
<br />Oct. 2007
<br />Form PUR 7068 (l\.e\-. 06/11/92)
<br />
<br />00402-2
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