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275-030-13 <br /> EQUAL OPPORTUNITY OFFICE <br /> 07/09 <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 commitment <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 /> Box 3: FDOT LAP Contract No. —The project's Local Area Project ('LAP') number <br /> Box 4: County—County or counties project work is being performed in <br /> Box 5: District or Local Agency—The Department's District Number Designation where the project is located Districts <br /> are 1-7, and the Turnpike District or the name of the city, county or entity administering the contract <br /> Box 6: Prime Contractor Name—The name of the prime contractor. <br /> Box 7 Company Name of Contractor, Supplier, Rental Company or Agency Submitting this certification—name of <br /> company submitting the certification <br /> Box 8: FEID No. — Federal Identification Number of company named in Box 7 <br /> Box 9: Name (first, last (of corporate official signing certification. — First name, last name <br /> Box 10: Job Title of person named in Box 9—job title <br /> Box 11: Signature of Certifying Official—signature of person named in Box 9 <br /> Box 12: Date of signature—Month/day/year of signature <br /> 00470-2 <br />