Fort Walton Beach Council agenda — 03-12-13--regular — reading text

statement and will notify the employer of any conviction of, or plea of guilty or nolo contenders to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five ( 5) days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in a drug assistance or rehabilitation program if such is available in the employee' s community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug -free workplace through implementation of Paragraphs I through 5. Check one: , / t' As the person authorized to sign this statement, I certify that this firm complies fully with above requirements. 0 As the person authorized to sign this statement, this firm does not 0M a comply fully with the above requirements. Dial Communications NAME OF BUSINESS: caE BY: l n SIGNATU Nelson I. Sweeney III, Vice — President / General Manager NAME & TITLE, TYPED OR PRINTED 8 of 28  M CN U N W C wN w 0NNN_ W N W O Vi UC3 V I O OM G C aLL ti C n Z v rdE C A Q C Packet Pg. 1  15.2. F F V W. 1ton laadmg S d Syste RFP 413. 010 PUBLIC ENTITY CRIME FORM - RFP 13 -010 SWORN STATEMENT UNDER SECTION 287. 133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted with Proposal, Proposal or Contract # RFP # 13 - 010 This sworn statement is submitted by Dial Communications whose business address is P. O. Box 6649 Tallahassee, FL 32314 - 6649 and ( if applicable) Federal Employer Identification Number ( FEIN) is 59- 3597149 ( If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement). My name is Nelson I. Sweeney III and my relationship to the entity named above is Vice — President / General Manager I understand that a " public entity crime" as defined in Paragraph 287. 133( a)( g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any proposal or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. I understand that " convicted" or " conviction' as defined in paragraph 287. 133( a)( b), Florida Statutes, mc0 means finding of guilt or a conviction of a public entity crime with or without an adjudication of guilt, in any federal or state trial court of records relating to charges brought by indictment or qUc information after July 1, 1989, as a result of ajury verdict, non -jury trial, or entry of a plea of guilty or nolo contenders. EEE U I understand that an " affiliate" as defined in Paragraph 287. 133( 1)( a), Florida Statutes, means: m0 0 A predecessor or successor of a person convicted of a public entity crime ( or) 0 ci An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term " affiliate" includes nLK those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one of shares constituting a controlling income among persons when not for fair interest in another person, cmEL A or a pooling of equipment or income among persons when not for fair market value under a a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate. 9 of 28  151 Fort Walton Laodin Sound S ste RFP # 13 -010 I understand that a " person" as defined in Paragraph 287. 133( 1)( e), Florida Statutes, means any natural person or entity organized under the laws of the state or of the United States with the legal power to enter into a binding contract for provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term " person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active n management of an entity. 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.) V Neither the entity submitting this swom statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor affiliate ofthe entity have been charged with and convicted ofa public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, o executives, partners, shareholders, employees, members, or agents who are active in management of o the entity or an affiliate of the entity has been charged with and convicted of a public entity crime A subsequent to July 1, 1989. ( Please attach a copy of the final order.) G. U. C The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer ofthe State of Florida, Division of Administrative Hearings. The a 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 copy of the final order) in The person or affiliate has not been placed on the convicted vendor list. (Please describe any H action taken by, or pending with, the Department of General Services.) g u Signature) E 0 Date) mp 0 Florida COUNTY OF: Leon STATE OF: 90oS PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being LL sworn by me, affixed his /her signature at the space provided above on this - 4/ { h day c of L[/ LP I../' 2013, and is personally known to me, or has EE provided as identification. Ln Notary Public My Commission expires O..d(+,(,,, r1 1 ole 15 MEN Pak - MME d I 10 of 28