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<br />officers, directors, executives, partners, shareholders, employees, members, and agents who are active in
<br />management of any entity.
<br />
<br />o
<br />
<br />11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity
<br />submitting this sworn statement. (Indicate which statement applies.)
<br />
<br />~ Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<br />_ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
<br />
<br />_ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the
<br />entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has
<br />been a subsequent proceeding before a Hearing Officer of the State of Rorida, Division of Administrative Hearings
<br />and the Final Order 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 place the entity
<br />submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.)
<br />
<br />I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC
<br />ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS 0
<br />FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO
<br />UNDERSTAND THAT I AM REQUIRED TO INFORM T E PUBLIC ENTITY PRIOR TO ENTERING INTO A
<br />CONTRACT IN EXCESS OF THE THRESHOLD UNT PROVIDED IN SECTION 287.017, FLORIDA
<br />STATUTES, FOR CATEGORY TWO OF ANY, CH IN THE IN ~TI CONTAINED IN THIS FORM.
<br />By:
<br />
<br />
<br />(Signature
<br />Steven M. nson
<br />(Printed Name)
<br />Corporate Secretary
<br />(Title)
<br />
<br />Sworn to and subscribed before me this ~ day of ~^\A~ +- ,20 rYt , by
<br />. 'j "\
<br />
<br />(AFFIX NOTARY STAMP HERE) r-k~~~
<br />( I - .
<br />JENNILEE JUNE WITT Sl'9n ture: Notary Public - State otFIorIda'. . ~tJ
<br />Notary Public-State of Minnesota
<br />~6~~~~~s~~~ ~x8~~ \. e Y\JU I} 1 j I W ( ti-
<br />Print or Type Commissioned Name
<br />
<br />Personally Known -to vu..,OR Produced Identification
<br />Type of Identification Produced
<br />
<br />
<br />END OF SEcnON
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<br />60
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