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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E. or E.1. APPLICANTS <br />I, /JJAflLfirr fir$ /J4Iticy , the representative of <br />Applicant Name <br />1/14` GRAC f Int( ) AE/56 Liae £ jT, �'�t�c, , do hereby attest that the <br />Business Name of Service <br />above named service meets all the requirements of, and that I agree to comply <br />with, all applicable provisions of Chapter 304, Life Support and Wheelchair <br />Services. <br />AL ANTS <br />1, Hfl(sR 1.46,t3v s .7" /5,� , the representative of <br />Applicant Name <br />1(125 L vF ;/tc ) if SW( ronti;—�t/t_. , 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 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 />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 statemen s on this application are tr and orrect. <br />APPLICANT SIGNATURE- 'DAME <br />Before me personally appeared the said 1% R (A1.--11,,,t)),-;S BAAA ' who says <br />that he/she executed the above instrument of his/her own free will and accord, with full <br />knowledge of the purpose thereof. Sworn and subscribed in my presence this .5 day of <br />Autiv,S< , 2015_. <br />',0-`'".4‹ ..: SHAWN G WEINSTOCK <br />R, MYGOMM)SSION#FFv3t533z <br />.t11OTA� iPI IIfil <br />••;'E��o?� y 15. 2017 <br />(407).333-0153 FloridallotaryService.com <br />My commission expires: <br />U\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />5 153 <br />