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Fort Walton Beach Council agenda — 04-26-11 regular — reading text
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includes those officers, directors,
executives, partners, shareholders, employees, members, and agents who are active n
management of an entity.
8. Based on information and belief, the statement which I have marked below is true in
relation to the entity submitting this sworn statement. ( Please indicate which statement
applies)
Neither the entity submitting this sworn statement, nor any officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in management of the
entity, nor affiliate of the entity have been charged with and convicted of a public entity crime L
subsequent to July 1, 1989. L
d
The entity submitting this sworn statement, or one or more of the officers, directors,
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executives, partners, shareholders, employees, members, or agents who are active in
management of the entity or an affiliate of the entity has been charged with and convicted of a
public entity crime subsequent to July 1, 1989. ( please attach a copy of the final order) 0
T
a
The person or affiliate was placed on the convicted vendor list. There has been a
subsequent proceeding before a hearing officer of the State of Florida, Division of
Administrative Hearings. The final order entered by the hearing officer determined that it was
in public interest to remove the person or affiliate from the convicted vendor list. ( please attach a
a copy of the final order)
00MN
The person or affiliate has not been placed on the convicted vendor list. ( Please
describe any action taken by, or pending with, the Department of General Services.) c
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Signature) a
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Date)
a
STATE OF:
J
COUNTY OF:
PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after
first being sworn by me, affixed his /her signature at the space provided above on this
a
day of 2011, and is personally known to me, or has
provided as identification.
Notary Public
My Commission expires:
Page 93 of 93
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