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<br />.
<br />
<br />.
<br />
<br />.
<br />
<br />executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<br />11.6.
<br />
<br />Based on information and belief, the statement which' I have marked below is true in relation to
<br />the entity submitting this sworn statement. (Indicate which statement applies.)
<br />
<br />j
<br />
<br />Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in the management of
<br />the entity, nor any affiliate of the entity has been charged with and convicted of a public entity
<br />crime 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
<br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity
<br />crime subsequent to July 1, 1989.
<br />
<br />The entity submitting this swom statement, or one or more of its officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in the management of
<br />the entity, or an affiliate of the entity has been charged with and convicted of a public entity
<br />crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a
<br />Hearing Officer of the state of Rorida, Division of Administrative Hearings and the Rnal Order
<br />entered by the Hearing Officer of the State of Rorida, Division of Administrative Hearings and the
<br />Rnal Order entered by the Hearing Officer determined that it was not in the public interest to
<br />place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of
<br />the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF nus FORM TO THE CONTRACITNG OFFICER FOR THE
<br />PUBUC EN11lY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBUC ENTTIY ONLY
<br />AND, THAT THIS FORM IS VAUD THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS
<br />FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBUC ENTTIY PRIOR TO
<br />ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECITON
<br />287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM.
<br />
<br />By:
<br />
<br />
<br />(Printed Name)
<br />
<br />(Title)
<br />
<br />
<br />/ S~om tta.nd. subscribed before me this
<br />f,,-v/4 ~:vt' ~r.:f1';"2. }A.
<br />r
<br />
<br />I
<br />
<br />day of
<br />
<br />, 20fL by
<br />
<br />f
<br />
<br />Signature: No~ry Pu lie - state of Florida
<br />, ~
<br />
<br />Print or Type Commissioned Name
<br />
<br />Personally Known j OR Produced Identification
<br />Type of Identification Produced
<br />
<br />(AFFIX NOTARY STAMP HERE)
<br />
<br />END OF SECTION
<br />
<br />NOTARY PunUC-:-STATE OF FLORIDA
<br /><1>""''''''# K rt V. In
<br />.W~ U . gram
<br />\~ iCon~missbn # DD72388S
<br />""""".., ExpJr~s: OCT. 19,2011
<br />BONDED nIRU Afu.'iTlC .lL;NiJING CO. INC.
<br />
<br />PAGE 73 OF 92
<br />BID No. 07-lQ-04
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