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V. NOTARIZED STATEMENTS <br />1, Brooke Taylor , the representative of <br />Applicant Name <br />Coastal Health Systems of Brevard,lnc., 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 />APPLICANT SIG6�TURE DATE <br />f <br />Before me personally appeared the said Brooke Taylor who says <br />that he/she executed the above instr ent of his/her own free will and accord, with full <br />knowledge of the purpose thereof. S rn and subscribed in my presence this 20th day of <br />February , 2024 <br />My commission expires: 06/06/24 <br />ARY <br />=o�PRY.P;�9tc FELICIA B. DEVOE <br />COMMission # GG 984937 <br />�v'lo� Expires June 6, 2024 <br />OF FL Bonded TtVU eudge(Netary swr jces <br />UAFiRE ADMIN ASSISTANTS\Beth\Beth Casano EOC\COPCN RENEWAL PACKETS\COPCN Application.doc <br />103 <br />