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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br /> E or El APPLICA TS <br /> I, ` , the representative of <br /> Applicant Name <br /> .lA( , 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 /> 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 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 /> �L <br /> I further acknowledges 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 application are true and cnoroct. <br /> APPLICANT SIGNATUR DATE <br /> Before me personally appeared the said_ 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 /4� day of <br /> �- 111- My commission expires: <br /> NOTARY PUBLIC <br /> ?L .uEATi i2 BCahiTA DALES <br /> Vy COMMISSION#DD945283 <br /> t7:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETSICOPCN Application rev.2013.doc '? F,iS� EXPIRES February 05S5,2014 <br /> (407)398-0?53 F oridallotaryService'Com <br /> 82 <br />