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V. 140TARIZED STATEMENTS <br />i, Mark Shaw , the representative of <br />Applicant Name <br />Indian River Shores PublIc Ski Department. <br />. do hereby attest that <br />Business Name of Service( <br />the above named service wlll 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 Sn ambulance service in the State of Florida as <br />provided in Chapter 401, Part HL Florida Statutes, Chapter 64E-2, Florida <br />Administrative Code, and that I agree to comply with all the provisions of Chapter <br />504, Life Support Services. <br />ALL APPLICANTS <br />I further acknowledge that discrepancies discovered during the effective <br />period of the Certificate of Pubic Korn ence and Necessity will subject <br />this service and its authorized representatives to corrective action Ind <br />penalty provided in the referenced authority and that to the best of kyr <br />knowledge, all statements on this application are true and correct, <br />Before me person <br />that he/she execu <br />knowledge of the <br />bMf q- 202, <br />VIC- <br />r Y <br />j W LICANT SIGNATURE IDATE <br />r:;,:�....,. who says <br />has/her own freewill and accord;� full <br />nc ibed in my presence tkiis day of <br />My commission expp%li AWI(Ac3 <br />: ; ► CHARLENE WIL <br />*y COMMISSION # HH 109873 <br />EXPIRES: July 26,2025 <br />Bonded Tfn Notary Public Undemilen <br />UAFIRE ADMIN ASSISTANT&Seth1Beth-Casano EWCORMRENEWAL PACKETrACOACN Applicallon.doc 5 <br />153 <br />