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<br />executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<br />11.6. 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 />./
<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 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. However, there has been a subsequent proceeding before a
<br />Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order
<br />entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the
<br />Final 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 THIS FORM TO THE CONTRACTING OFFICER FOR THE
<br />PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY
<br />AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS
<br />FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO
<br />ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION
<br />287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION
<br />CONTAINED IN THIS FORM.
<br />
<br />
<br />By:. '\
<br />~. . ' 0---- '--------
<br />(Signature) 1\
<br />l-'\. D.. N v ~'-' {:>...-'-l. \ 0(.. :J
<br />(Printed Name)
<br />~ ..> "'& I.N -5'5;:' CJ E--..l €:: "- ,:;{, fS (I......
<br />(Title)
<br />
<br />and subscribed before me this yf) day of
<br />
<br />...
<br />
<br />('
<br />
<br />
<br />, 20Jil by
<br />
<br />(AFFI N9!~ ~~ I3MI2~NUEV A
<br />
<br />~ MY COMMISSION # DD542526
<br />
<br />~I"t...i EXPIRES: Apr. 19,2010
<br />OFf' S' m
<br />(407) 398'()153 FIOOda Notary arvlce.co
<br />
<br />Cne: 01{A\Pl~iC - Sta(lo~ 2{rida
<br />'4 J a FlU v
<br />Print or Type Commissioned Name
<br />
<br />Personally Known ^ OR Produced Identification
<br />Type of Identification Produced
<br />
<br />END OF SECTION
<br />
<br />PAGE 73 OF 92
<br />BID No, 07-10-04
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