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V. NOTARIZED STATEMENTS <br />I, Mark Shaw , the representative of <br />Applicant Name <br />Indian River Shores Public Safety Department 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 />AP LICANT SIGNATURE DATE <br />Before me personally appeared the said 6MCW who says <br />that he/she executed the above instrument of his/her own free will and accord, with full <br />knowledge of the pur ose thereof. Sworn d s scribed in my presence this; day of <br />(2�Xuaf�j 2024 _ <br />My commission expires:,. _l IL 0(01�aaS <br />NOTARY PUBLIC <br />FF. <br />CHARLENEHALL <br />MY COMMISSION N HH 109873 <br />EXPIRES: July 26, 2025 <br />Bonded 7hru Notary PuNic Undamiten <br />U:\FIRE ADMIN ASS I STANTS\BethlBeth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Applicalion.doc <br />94 <br />