Laserfiche WebLink
275-030-13 <br /> EQUAL OPPORTUNITY OFFICE <br /> 07109 <br /> Certification of Non Segregation & Non Discrimination <br /> Instructions for Completing Form <br /> This form is provided to contractors an 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 /> 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 /> 'I <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, fast(of corporate official signing certification.—First name, last name j <br /> Box 10:Job Title of person named In Box 9—job title <br /> i <br /> Box 11:Signature of Certifying Official—signature of person named in Box 9 l <br /> Box 12: Date of signature—Month/daylyear of signature <br /> i <br /> I <br /> i <br /> I <br /> • i <br /> I <br /> 1 <br /> 00490-2 <br />