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275-030-13 <br />EQUAL OPPORTUNITY OFFICE <br />07!09 <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 Financia( 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 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, fast (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 />