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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 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 /> 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: FEW 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 /> 00490-2 <br />