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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.
<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 />-i-
<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 />By: /~4.~~ A
<br />(/e~c--.?/' c---y
<br />
<br />(Signature)
<br />(:)JL) tJr.-l ots CYT'6(2{)
<br />(P;:ifIted Name)
<br />'(~l}:?~
<br />(Title)
<br />
<br />Sworn to and subscribed before me this q. -t!:- , 20 C-::r, by
<br />vi)) ,c/'
<br />
<br />
<br />
<br />gnature: Notary ublic - State of Florida
<br />fu t:m-I /1 V1:J-t-I)E ':> .
<br />Print or Type Commissioned Name
<br />
<br />
<br />m~tJOTARY ~~~RF)
<br />I :ti~ Notary Pu'bi(c'~ ~tate Of Fronda
<br />~. .! My CommIssion expires Oct 25. 2011
<br />~~~ ~1 Commission' DO 729259
<br />",,,t~:.r,~,,\, Bonded Through NaIIonaI NoIlIy Assn.
<br />
<br />Personally Known;X 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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