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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 APPLICANTS <br />I, ,C , the representative of <br />Applicant Name I <br />UL v � c�O %k -c eA tv, do hereby.attest that the <br />Business ame of Service <br />above named service me is all the requirements of, and that 1 agree to comply <br />with, all applicable provisions of Chapter 304, Life Support and Wheelchair <br />Services. <br />A -D APPLICANTS <br />1, , the representative of <br />Appl cant Name <br />VUR S do hereby attest that <br />Business Name of lervice <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 representati ective action and <br />penalty provided in the referenced au r ty and th t t the best of my <br />knowledge, all statements on this p4 lign arp. u and correct. , <br />TURE DATE <br />Before me personally appeared the said JR f" l UL�7L '0\00 � 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 �,�ay of <br />My commission expires: <br />NOTARY PUBLIC <br />go ft Notary Public State of Florida <br />?° Kathleen Bree <br />My Commission GG 929701 <br /><h��Q� Expires I2JI012023 <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />36 <br />