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V: NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 APPLICANTS <br />1, , the representative of <br />Applicant Name <br />, do hereby attest that the <br />i 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 />Service's. <br />A -D APPLICANTS <br />I, PyNc )cls, 6 '�ose\� , the representative of <br />Applicant Name <br />-To<A\o,n?,we< SY-�04P5 �.�b\�c �e I , 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 />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 o is applicatio re ue apyl-'ngrrect. <br />APPLICANT SIGNATURE DATE <br />I p i <br />Before me personally appeared the saidT�\C�'�:C(\[,� P,�, 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 a cribed in my presence this �51 day of <br />aCCO 201(,'). <br />My commission expires: % ftlo�-7 <br />NOTARY PUBLIC <br />CHARLENE HALL <br />:= Commission # FF 007183 <br />U*\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc =�' Expires July 26, 2017 5 <br />%r'� pi n,• B.,ded Tlw Troy Fen Ineururu 800 3857019 n <br />