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275-030-13 <br /> EQUAL OPPORTUNITY OFFICE <br /> 07M <br /> Certification of Non Segregation & Non Discrimination <br /> Instructions for Completing Form <br /> — This form is provided to contractors on federally assisted road and bridge construction projects to affirm their commitmer , . <br /> to nondiscrimination and non segregated facilities during the term of a contract. <br /> Box 1 : Fin. ProJ No. — The Financial Project Number <br /> Box 2 : FAP No . — The Federal Aid Project Number assigned to federally funded projects or 'non-FAP <br /> ' <br /> — Box 3: FDOT LAP Contract No. — The project's Local Area Project ('LAP') number <br /> Box 4 : County — County or counties project work is being performed in <br /> Box 5: District or Local Agency — The Department' s District Number Designation where the project is located Districts <br /> are 1 -7, and the Turnpike District or the name of the city , county or entity administering the contract <br /> -- Box 6: Prime Contractor Name — The name of the prime contractor. <br /> Box 7: Company Name of Contractor, Supplier, Rental Company or Agency Submitting this certification — name of <br /> company submitting the certification <br /> Box 8: FEID No. — Federal identification Number of company named in Box 7 <br /> Box 9: Name (first, last (of corporate official signing certification . — First name, last name <br /> Box 10: Job Title of person named In Box 9 — job title <br /> Box 11 : Signature of Certifying Official — signature of person named in .Box 9 <br /> Box 12: Date of signature — Month/day/year of signature <br /> 00490 - 2 <br />