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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 APPLICANTS <br />I, , the representative of <br />Applicant Name <br />do hereby attest that the <br />Business Name of Service <br />above named service meets all the requirements of, and that l agree to comply <br />with, all applicable provisions of Chapter 304, Life Support and Wheelchair <br />Services. <br />A -D APPLICANTS <br />the representative of <br />Applicant Name <br />Business Name of Service <br />do hereby attest that <br />the above named service will provide continuous service on a 24-hour, 7 -day <br />week basis. I do hereby attest that the above named service meets all the <br />requirements for operation of an ambulance service in the State of Florida as <br />provided in Chapter 401, Part III, Florida Statutes, Chapter 64E-2, Florida <br />Administrative Code, and that I agree to comply with all the provisions of Chapter <br />304, Life Support Services. <br />ALL APPLICANTS <br />further acknowledge that discrepancies discovered during the effective <br />period of the Certificate of Public Convenience and Necessity will subject <br />this service and its authorized representatives to corrective action and <br />penalty provided in the referenced authority and that to the best of my <br />knowledge, all statements on this appUqAtion ari,trijera�d correct. <br />UVIA1 <br />Ai5PL'1CANT ATURE DATE <br />Before me personally appeared the said _ cs � ? who says <br />that he/she executed the above intrument of his/her own free will and accord, with full <br />knowledge of the'purpose Cher, --S and subscribed in my presence this ��day of <br />2OIL <br />'' My commission expires: <br />NCS <br />FEU'.dpl F3. DEVoi= <br />* ray COMM ISS ION 0 EE 166703 <br />EXPIRES: June 6, 20f8 <br />tJ:19e4h18eth Gasano E0000PCNIRENEWAL PACKETS=PCN Application.doc w�',, ,,OF r Bended Thru Budpl*arj SeyjCe3 <br />