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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 APPLICANTS <br />1, ('L -U (S (. 'S <br />the representative of <br />Applicant Name <br />do hereby attest that the <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 />I <br />Applicant Name <br />Business Name of Service <br />the representative of <br />do hereby attest that <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 on this application are true and correct. <br />AP LIC T IG -NATURE bAtE <br />Bef me personally appeared the said (,V%5 <br />t t h /she executed the above instrument of his/her o <br />n edg a ;,;,6s thereof. Sworn and subscrib <br />201 <br />NOTARY PUBLIC <br />G. (7,*W who says <br />wn free will and accord, ith ull <br />ed in my presence this day of <br />My commission expires: <br />I <br />YEE <br />lic State of Florida <br />U-1Beth\Beth Casano EOCICOPCMRENEWAL PACKETSICOPCN Application docndersonssion FF 1917365 <br />/27/2019 <br />J <br />