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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 APPLICA_NTS', <br />1, PF ORO e0J 0 S , the representative of <br />Applicant Name <br />O'o N ton e -e l ags Pon bPR o e Ps, /&4. 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, , the representative of <br />Applicant Name <br />, do hereby attest that <br />Business Name of Service <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 lication are true and correct. <br />APPLICANT SIGNAT6fiE DATE <br />Before me personally appeared the said ���� A�i)o U >q`/ who says <br />that he/she executed the above instrument of his/her own free will and accord, with, ull <br />knowledge of the purposeth of. Sworn a d subscribed in my presence this =; day of <br />201 �o. 094Q,�My <br />commission expires: <br />NOTARY PUBLIC <br />GAIL L. CAIN <br />Notary Public, State of Florida <br />U•1Beth\Beth Casano EOCICOPCNIRENEWAL PACKETSICOPCN Application.doc My comm exp. Oct. 21, 2017 <br />Comm. No. FF 58217 <br />P43 <br />