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EQUAL OPPOR_nJN17YUFHCE <br /> niios <br /> Certification of Non Segregation & Non Discrimination <br /> Instructions for Completing Form <br /> This form is provided to contractors on federally assisted road and bridge construction projects to affirm their commitmer,. <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 Number assigned to federally funded projects or'non-FAP' <br /> M <br /> Box 3: FDOT LAP Contract No.—The project's Local Area Project(`LAP') number h <br /> Box 4: County <br /> _Countyor counties prblect work is being performed in <br /> I3oX 5: Dlsariot or LOd9I A �- <br /> O6hcy The Department's District Number Designation where the prod; is located Districts <br /> the Tum iko District or the name of the oity, county or entity administering the contra' <br /> are 14, and P <br /> Boxy Pi`tm Cglittl�oto[r Name--The name of tfie pnme contra .or,. <br /> Box'1ompatt. "Ma..mie of Contractor,Supplier,F�eetal.Company or Agency Submitting this.certif cation_-name of <br /> y <br /> company submi�.nJ the cedification <br /> gox a= Ffrlb No.—WON Identification Number of Orripany named in.W7 <br /> Box 9;Name(first, ias>tOf corporate offclal signing certification. First name, last name <br /> Box 10Jbb Title of person n0oled in.9ox 9—job title. <br /> Box 11 Signature of Certifying OW1611al—signature of person named in Box 9 <br /> Box 126.Date of signature>—Mdrithlday(year of signature <br /> w <br />