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• transacts or applies to transact business with a public entity. The term "persons" includes those
<br />officers, directors, executives, partners, shareholders, employees, members, and agents who are
<br />active in management of any entity.
<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 />0Neither 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 />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 />i 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 />IS the final order.)
<br />•
<br />•
<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 />By:
<br />(Signatu/
<br />(Printe Name)
<br />(Title)
<br />Sworn to and SUbscriff d before me this
<br />7, 1 S /4- A') /-L) FA A J?JE
<br />day of 1) 1Ce-M�- ,C f ,20 (U ,by
<br />c
<br />(AF F STAMP HERE ) 3�, r "
<br />............
<br />EILEEN DOMINGUEZ Si natur Not r lic —Slate
<br />MY COMMISSION # DD 812645 -e e U0 r'V)
<br />EXPIRES: August 7,2012 Print or Type Commissioned Name
<br />fir` of —1-.1cf1 Bonded Thru Notary Pubic Underwriters
<br />Personally Known 0 oduced Identi is ion
<br />Type of Identification Produced ,
<br />END OF ECTION
<br />PAGE 88 OF 105
<br />PROPOSAL N0.
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