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275-03043 <br /> EQUAL OPPORTUNITY OFFICE <br /> 07109 <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 (TAP') 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 14, 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 inBox 9 <br /> Box 12: Date of signature — Month/day/year of signature <br /> p .. <br /> } ,F . <br /> ,, 00490- 2 <br />