Laserfiche WebLink
<br />6. Based on information and belief, the statement which I have marked below is true in relation to <br />the Person submitting this sworn statement. (Indicate which statement applies.) <br /> <br />X (1) Neither the Person submitting this sworn statement, nor any officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in the management of the <br />Person, nor any Affiliate of the Person has been charged with and convicted of a public entity crime <br />subsequent to July 1,1989. <br /> <br />_ (2) The Person submitting this sworn statement, or one or more of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in management of <br />the Person, or an Affiliate of the Person has been charged with and convicted of a public entity crime <br />subsequent to July 1, 1989. <br /> <br />_ (3) The Person submitting this sworn statement, or one or more of its officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in the management <br />of the Person, or an Affiliate of the Person 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 Hearing <br />Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by <br />the Hearing Officer determined that it was not in the public interest to place the Person submitting <br />this sworn statement on the convicted vendor list. (attach a copy of the final order) <br /> <br />THE UNDERSIGNED UNDERSTANDS AND ACKNOWLEDGES THAT THE SUBMISSION OF <br />THIS FORM TO MDX IS FOR MDX ONLY AND THAT THIS FORM IS VALID THROUGH <br />DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED WITH MDX. I ALSO <br />UNDERSTAND THAT I AM REQUIRED TO INFORM MDX PRIOR TO ENTERING INTO ANY <br />CONTRACT WITH MDX OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS <br />FORM. <br /> <br />~u A- y~ <br /> <br />SIGNATURE OF AFFIANT <br /> <br />Robert B. Deuser <br />(Printed or Typed Legal Name of Affiant) <br /> <br />State of Florida County of Broward <br /> <br />Sworn to and subscribed before me this 18th day of <br /> <br />May <br /> <br />, 20 lQ by <br /> <br />Robert B. Deuser, Vice President <br /> <br />Linda S. Scotece ~~:1- ~ <br />Notary's Name Printed, Stamped or Typed <br /> <br />.,.Uh, <br />l~:"'!U~.~ LINDA S. SCOTECE <br />~./,JJ;,'\.~ MY COMMISSION N DO 711648 <br />~A~i EXPIRES: December 13, 2011 <br />. "Rfll~"" Bonded Thru Notary Public Underwriters <br /> <br />Notary Seal: <br /> <br />Personally Known: <br /> <br />x <br /> <br />or Produced Identification~ <br />