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V. NOTARIZED STATEMENTS Fill in Statements as applicable. <br />E or E1 APPLICANTS <br />I, Karen Deigi , the representative of <br />Applicant Name <br />Senior Resource Association, Inc. , 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 />M <br />Applicant Name <br />Business Name of Service <br />the representative of <br />do hereby attest that <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 />8/1812021 <br />APPLICANT SIGNATURE DATE <br />Before me personally appeared the said r , ��.: { : ; 5 ; '��, <--1_� who says <br />that he/she executed the above instrument of his/her own'free will an accord, with full <br />knowledge of the purpose thereof. Sworn and subscribed in my presence this r day of <br />2031. <br />My commission expires: <br />]NOTA ,Y..PUBUC <br />LOUISE M BATISTA <br />WBelh\Deth Casano EOCICOPMRENEWAL PACKETSICOPCN Applicati ,11 c t=Notary Public -State of Florida 5 <br />Commission # HFI 82673 <br />,Fo My Commission Expires <br />�e���'�� nu r 1. 2026 39 <br />