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2019-091
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2019-091
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Last modified
12/27/2019 1:32:58 PM
Creation date
6/17/2019 11:32:41 AM
Metadata
Fields
Template:
Official Documents
Official Document Type
Agreement
Approved Date
06/11/2019
Control Number
2019-091
Agenda Item Number
12.F.1.
Entity Name
Consor Engineering
Subject
CEI services
Area
43rd Avenue from 18th Street to 26th Street
Project Number
IRC-0853
Bid Number
2019040
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2019040 - RFQ for CEI Services - 43rd Ave <br />A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />,Et�C4 I Bf LARK <br />Neither the entity submitting this sworn statement, nor any officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in management of the <br />entity, have any relationships as defined in section 105.08, Indian River County Code, with any <br />County Commissioner or County employee. <br />The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents, who are active in <br />management of the entity have the following relationships with a County Commissioner or <br />County employee: <br />Name of Affiliate Name of County Commissioner Relationship <br />or entity or employee <br />STATE OF <br />COUNTY OF <br />(Signature) <br />(Date) <br />The foregoing instrument was acknowledged before me this day of , 20 , by <br />who is personally known to me or who has produced <br />as identification. <br />SIGN: <br />NOTARY PUBLIC <br />PRINT: <br />Page 13 of 15 <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) <br />
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