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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or El APPLICANTS <br />I, N � ,r �, � q w � � s t� �� w k 05 <br />Applicant Name <br />, the representative of <br />�J r_ e c, e, o f -j L s t) v z Coe, ildo 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 />17 ( C; ✓ , 4 IAA, <br />Applicant Name <br />ra = �-✓�1/-1'1 , the representative of <br />e c S u r z Coo, st do hereby attest that <br />Business Name of Service <br />of <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 agplica true and correct. <br />APPLICANT SIGNATURE <br />ATE <br />Bef e me personally appeared the said /%a v, kof 8€1.v1 £Z`s who says <br />t at he she executed the above instrument" `f -his er own free will and accord, with full <br />li.Qowledge of the purpose thereof. Sworn and subscribed in my presence this 20c—clay of <br />(J,'vs'b , 2013: 9 <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Appli <br />My commission expires: ►--=2- I -e <br />JAIME ORTIZ <br />. t� UB'Si <br />•s Notary Public - State of Florida <br />•c My Comm. Expires Jun 1, 2018 <br />ap' Commission # FF 111485 <br />''°' t°P• Bonded Through National Notary Assn. <br />5 <br />P76 <br />