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r. <br />,.75-6304 L- <br />E <br />E•POR711N(TY OFFICE <br />- .. (17rn9 <br />Certification of Non Segregation & Non Discrimination <br />:Instructions for Completing Form <br />This form is provided to contractorson federally assisted road and bridge construction projects to affirm their commitmei, <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.Nuniber assigned to federally funded projects or 'non -FAP' <br />Box-3:.FDOT LAP Contract No. — The projecVs Local Area Project ('IAP')number =, <br />. <br />Boz 4: County <br />County or counties paired is being �performed <br />BOX 5: District or Local Agency—The Department's Distract -Number Designation where the project is located Districts <br />are 1-7, and the Turnpike District or the: name of thecity, county or entity administering the contract' <br />Box.6 prime Contractor Name,.Thename of theprinle:Contractor: <br />Box 7 CompanyName of Contractor,:Supplier, Rental Company or Agency Submitting this certification — name of <br />companysubmitting the certification. <br />Box :8 FEID No.— Federal Identification _Number.of.company named in Box. <br />7 <br />Box a Name (first, last(of corporate official signing certificatio'n. —First name, last name <br />Box 1D: Job Title of person named in '59x 9—job:title. <br />Box 11° Signature of Certifying-Officiai — signature of person named itiBox 9 <br />Box 12: Date of signature.— Moritfi/daylyear of:signature <br />604.97)-9 <br />