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Page 2 of 5 <br /> 2. Updated Construction Schedule per Specification Section 01310, and <br /> Dated By: <br /> (CONTRACTOR— must be signed by <br /> an Officer of the Corporation) <br /> Print Name and Title <br /> STATE OF FLORIDA <br /> COUNTY OF INDIAN RIVER <br /> Before me, a Notary Public, duly commissioned, qualified, and acting, personally appeared <br /> who being by me first duly sworn upon oath, says that he/she is the <br /> of the CONTRACTOR mentioned above and that he/she has been duly <br /> authorized to act on behalf of it, and that he/she executed the above Contractor's Application for <br /> Payment and Contractor's Certification statement on behalf of said CONTRACTOR; and that all of <br /> the statements contained herein are true, correct, and complete. Subscribed and sworn to before <br /> me this day of —120 <br /> is personally known to me or has produced <br /> as identification. <br /> NOTARY PUBLIC: <br /> (SEAL) Printed name: <br /> Commission No.: <br /> Commission Expiration: <br /> Please remit payment to: <br /> Contractor's Name: <br /> Address: <br /> [The remainder of this page was left blank intentionally] <br /> 00622-Contractor's Application for Payment-03-10 re'v <br /> 00622-2 <br /> F\Public Works\ENGINEERING DIVISION PROJECTS\1619 Round Island Facility Paving\1-Admin\bid documents\Master Contract Documents\00622-Contractor's Application for <br /> Payment-03-10 rev.doc Rev.05101 <br /> I <br /> 1 <br />