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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 />/
<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 ENTI1Y IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTI1Y 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 ENTI1Y 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: ~e- ~
<br />
<br />(SiqIlature) /? _ L , ~
<br />~~ ~D41/~c
<br />(Prjijted Name) ~I
<br />~f1">7~ ~~~~eJe
<br />(Title)
<br />
<br />f\ Sworn to\and subscribed before me this 5 day of Dt l cmbt'r
<br />r\C\ ((L'){l\\['(l
<br />
<br />, 20 (; 1, by
<br />
<br />~v lh\",[ J / 'J ;.~Jrtinez
<br />(AFFI~.,N6tARY ST~!V1P:H~Rf:).iilez LlLlJ l \, u.- " ' ~,,4/ J0532718
<br />.:, .'0582718 Signafure: NotarY ~,,~ - State..~f:Flor;I.~~. 08,2010
<br />t,,:,;,03,201O L\)\S(1 {lILI\' !Jilt li."'" \'..' ~'D~'~IOTARYcom
<br />'.",,,,,..... \'n." ,';por,NOTARY,COm Print or Type Commissioned Name
<br />
<br />Personally Known V 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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