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I C / �-lJJlr <br /> _- EQUAL OPPORTUNITY OFFIC <br /> 07A <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 /> 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 c <br /> company submitting the certification <br /> Box 13 : FBID 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 inBox 9 <br /> Box 12 : Date of signature — Month/day/year of signature <br /> 00490 - 2 <br />