Laserfiche WebLink
V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 AP,PLICANTS <br />I, Michael DeSouza, the representative of <br />Applicant Name <br />All County Ambulance <br />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 />1, Michael DeSouza , the representative of <br />Applicant Name <br />All County Ambulance , 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 application are true and correct. <br />" As� --^% - 310 ►8 <br />APPLICANT S1. TURE DATE <br />Before me personally appeared the said M 'i CY) a(-1 DC-!; b hZ-tom who says <br />that he/she executed the above instrument of his/her own free will and accord, with full <br />knowledge of the pu ose th =Sd subscribed in my presence this 8 day ofMarch, 2018. i, My commission expires: I 1 c j <br />NOTARY PUBLIC <br />OS�y Felecla Olmstead <br />o NOTARY PUBLIC <br />0 <br />STATE OF FLORIDA <br />C:\Users\jsalvesen\Desktop\Irtg Expi' i�� 972��i'ty Ambulance COPCN 2018.doc 30 <br />