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03/20/2018
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03/20/2018
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Last modified
1/11/2021 1:04:05 PM
Creation date
5/1/2018 2:11:07 PM
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Meetings
Meeting Type
BCC Regular Meeting
Document Type
Agenda Packet
Meeting Date
03/20/2018
Meeting Body
Board of County Commissioners
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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />Eo APPLIC S <br />I, Michael DeSouza, the representative of <br />Applicant Name <br />American Ambulance Service, 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, Michael DeSouza , the representative of <br />Applicant Name <br />American Ambulance Service, 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 />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 />3 /06JI& <br />APPLICANT 4tAATURE DATE <br />Before me personally appeared the said M*i ofhat_I t ,c-souz--a who says <br />that he/she executed the above instrument of his/her own free will and accord, with full <br />knowledge of the purpose thereof. Sworn and subscribed in my presence this 8 day of <br />March, 2018.`-44 Qe r,-, a , (�� Q � � My commission expires: oaj <br />NOTARY PUBLIC CSAR Felecia Olmstead <br />oar NOTARY PUBLIC <br />g c STATE OF FLORIDA <br />? Comm# GG064369 58 <br />C:\Users\jsalvesen\Desktop\ln Iver W2*dl jcan Ambulance Service COPCN 2018.doc <br />
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