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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 />Neither the entity submitting this sworn statement, nor any of its 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 />Byf~~
<br />
<br />(Sinnature) S
<br />4iliY1aA ~l
<br />(PriJIted NCW)e)
<br />ILl CE- ~ES"IOBD\
<br />(Title)
<br />
<br />Sworn to and subscribed before me this l~ tt day of -:Ill f\.!L , 20 CZ by
<br />
<br />(AFFIXNO .'''''. AV". 47~. sy:y
<br />;~'f";b.~;. MY COMMISSION · DO. 329.54~. Signatur . Notary p~' c - State of Florida
<br />'. ~:.~.~j EXPIRES: June 15'.._.~ j('"\ I' \
<br />I "!.i:P':::f.-~" Bonded Thill NoIilry Public '~ ':f ',' , U ~ l.l , F) ~ a r" a. ·
<br />
<br />Personally K=. / . 0: ~ro~Uced Identificati~rint or Ty e Commissioned Name
<br />
<br />Type of Identification Produced END OF SECTION
<br />
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