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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br /> E or E1 APPLICANTS <br /> 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 I 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 /> c� hCdo 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 aut fity and that to the best of my <br /> knowledge, all statements on this a ication are true and correct. <br /> APPLICANT SIG U E DATE <br /> Before me personally appeared the said � A\,c, C �� � who says <br /> that he/she executed the above instrument of his/her own free will and accor , with full <br /> knowledge of the purpose thereof. worn and subscribed in my presence this�_day of <br /> 201 . <br /> My commission expires: <br /> NOTAR <br /> FELIM B.WV0E <br /> * * My COMMISSION t EE 166703 <br /> d, EXPIRES:June 6,2016 <br /> U•\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc '�E�O."o, BmMThuW NowySevi= 5 42 <br /> I r <br />