Laserfiche WebLink
The entity submitting this sworn statement, or one or more of the officers, directors, executives, <br />partners, shareholders, employees, members, or agents, who are active in management of the entity <br />have the following relationships with a County Commissioner or County employee: <br />Name of Affiliate <br />or entity <br />STATE OF A-�+OY\t <br />COUNTY OF <br />Name of County Commissioner <br />or employee <br />Relationship <br />(Signature) <br />2.-2z.R <br />(Date) <br />The foregoing instrument -was acknowledged before me this 22 day of , 201La , by <br />\1(� ,who isersonal_y jmww_u to me or who has produced <br />M <br />as identification. <br />NOTARY PUBLIC <br />SIGN: <br />PRINT:�� <br />Notary Public, State at large <br />My Comrnission Expires: *,03 A9 <br />(Seal) c�_fiF��q��pvys `7 T <br />o��y PGB�H ��''i.7'Vi�.[['ggb VVESuA <br />MY COIvtMISSION # FF90457i3 <br />co gxp1RES: Octobea 03, 2019 <br />9 <br />00452-2 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1324 58th Ave Resurfacing (N. of 26th St to N. of 57th St)\1-Admin\Bid documents\Master <br />.Contract Documents\00452 Disclosure of Relationshins.dor,., <br />