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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or El APPLICANTS <br />I, e. A. 644Dce�y <br />Applicant Name <br />"like Arc OF IN0,A,1 Rt Ctivn3►y <br />, the representative of <br />, do hereby attest that the <br />Business Name of Service <br />above named service meets all the requirements of, and that 1 agree to comply <br />with, all applicable provisions of Chapter 304, Life Support and Wheelchair <br />Services. <br />A -D APPLICANTS <br />1, , the representative of <br />Applicant Name <br />, do hereby attest that <br />Business Name of Service <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 111, Florida Statutes, Chapter 64E-2, Florida <br />Administrative Code, and that 1 agree to comply with all the provisions of Chapter <br />304, Life Support Services. <br />ALL APPLICANTS <br />I 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 tj,is,application a e true aip correct. <br />8'13//,5 <br />APPLICANT SIGNOR <br />Before me personally appeared the said CADL e I <br />DATE <br />who says <br />tha he she executed the above instrument o his her own free will and accord, with full <br />knowledge of the purpose thereof. Sworn and subscribed in my presence this l �` day of <br />201 r. <br />NOTARY PUBLI <br />My commission ex <br />U\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />5 <br />146 <br />