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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or El APPLICANTS <br />1, , the representative (:If <br />Applicant Name <br />, do hereby attest that t e <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 />M k c c v)Orc) > <br />Applicant Name <br />, the representative <br />f <br />ncjI ,-N ?y,V - 1iA-Akc S -SE { DeQt.. , 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 a <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 C apter <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 this application are true and correct. <br />427/14 <br />APPLICA GNATURE DATE <br />Before me personally appeared the said \GCQE'.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 611 dajy of <br />VPYxIICkfk,1 , 201 4. <br />My commission expires: -70(01 <br />NOTARY PUBLIC <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />•:striii CHARLENE HALL <br />.., Co• <br />mmission # FF 00 183 <br />'a Expires July 26, 201 <br />IP'„P, ... Bonded Thru Troy Fain Insure 800-385-7019 <br />34 <br />